Provider Demographics
NPI:1285234419
Name:GANNON, AMANDA PAULETTE (LMSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:PAULETTE
Last Name:GANNON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:WARD COVE
Mailing Address - State:AK
Mailing Address - Zip Code:99928-0519
Mailing Address - Country:US
Mailing Address - Phone:907-204-0874
Mailing Address - Fax:
Practice Address - Street 1:344 FRONT ST STE A
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-6431
Practice Address - Country:US
Practice Address - Phone:572-999-0107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK215055104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1366719759Medicaid