Provider Demographics
NPI:1366768269
Name:GANNON, VICKI ANN (MA,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:ANN
Last Name:GANNON
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 GOLIAD DR.
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-3716
Mailing Address - Country:US
Mailing Address - Phone:915-755-3213
Mailing Address - Fax:
Practice Address - Street 1:5005 N. PIEDRAS ST.
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920-5001
Practice Address - Country:US
Practice Address - Phone:915-569-2073
Practice Address - Fax:915-569-1123
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10947235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist