Provider Demographics
NPI:1427257153
Name:GANNON, HOLLY M (LCAT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:M
Last Name:GANNON
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:M
Other - Last Name:TUPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCAT
Mailing Address - Street 1:113 SAINT MARKS PL APT 3W
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-5128
Mailing Address - Country:US
Mailing Address - Phone:646-202-1431
Mailing Address - Fax:
Practice Address - Street 1:5601 16TH AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1809
Practice Address - Country:US
Practice Address - Phone:718-686-1526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001107-1221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist