Provider Demographics
NPI:1306312236
Name:GANNON, BETTY LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:BETTY LYNN
Middle Name:
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 1:445 SMITH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:10590-2626
Mailing Address - Country:US
Mailing Address - Phone:203-216-2832
Mailing Address - Fax:
Practice Address - Street 1:134 N 4TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-3296
Practice Address - Country:US
Practice Address - Phone:646-450-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099880104100000X
CT4826104100000X
NY0995371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker