Provider Demographics
NPI:1962809699
Name:GANNON, MICHAEL WALSH (PHD, LCADC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WALSH
Last Name:GANNON
Suffix:
Gender:M
Credentials:PHD, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CLOUD TOUCH CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-7116
Mailing Address - Country:US
Mailing Address - Phone:916-318-5317
Mailing Address - Fax:
Practice Address - Street 1:109 CLOUD TOUCH CT
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-7116
Practice Address - Country:US
Practice Address - Phone:916-318-5317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1340101YA0400X
KY167168101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)