Provider Demographics
NPI:1386064582
Name:MCGANNON, MARY LAURA (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LAURA
Last Name:MCGANNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 DARLING RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:CT
Mailing Address - Zip Code:06420-3913
Mailing Address - Country:US
Mailing Address - Phone:860-639-1276
Mailing Address - Fax:
Practice Address - Street 1:29 MAIN ST
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1134
Practice Address - Country:US
Practice Address - Phone:860-639-1276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-27
Last Update Date:2014-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000176101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional