Provider Demographics
NPI:1063751782
Name:GANNON, ANGELA CAPPUCCILLI (LCSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:CAPPUCCILLI
Last Name:GANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7010 BRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-6006
Mailing Address - Country:US
Mailing Address - Phone:703-941-8810
Mailing Address - Fax:703-658-2378
Practice Address - Street 1:7010 BRADDOCK RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-6006
Practice Address - Country:US
Practice Address - Phone:703-941-8810
Practice Address - Fax:703-658-2378
Is Sole Proprietor?:No
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA16471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical