Provider Demographics
NPI:1912797887
Name:NOVAK, GANNON JOHN
Entity type:Individual
Prefix:
First Name:GANNON
Middle Name:JOHN
Last Name:NOVAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 SOUTH KANNER HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:407-595-2579
Mailing Address - Fax:
Practice Address - Street 1:6421 N FLORIDA AVE
Practice Address - Street 2:SUITE D-1458
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-6007
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician