Provider Demographics
NPI:1447952528
Name:GANNON, MCKENZIE ROSE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:ROSE
Last Name:GANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5828
Mailing Address - Country:US
Mailing Address - Phone:831-427-1007
Mailing Address - Fax:831-454-0545
Practice Address - Street 1:707 FAIR AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-5828
Practice Address - Country:US
Practice Address - Phone:831-427-1007
Practice Address - Fax:831-454-0545
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)