Individual
THERESA GANNON
Active
Individual
THERESA GANNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PH.D.
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
Primary
PSY16008
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
GR002104M
MEDI-CAL GROUP NUMBER
CA
01
—
PSY16008
PSYCHOLOGIST LICENSE #
CA
Enumeration date
11/23/2005
Last updated
02/22/2011
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