Provider Demographics
NPI:1215166228
Name:GANN, GEORGIA
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:GANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 S CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-5106
Mailing Address - Country:US
Mailing Address - Phone:847-825-7878
Mailing Address - Fax:
Practice Address - Street 1:1304 S CHESTER AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-5106
Practice Address - Country:US
Practice Address - Phone:847-825-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-11
Last Update Date:2009-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist