Provider Demographics
NPI:1528160652
Name:MCGANNON, MARY ANN M (LPC, ATR-BC)
Entity type:Individual
Prefix:MS
First Name:MARY ANN
Middle Name:M
Last Name:MCGANNON
Suffix:
Gender:F
Credentials:LPC, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 E LONG AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2516
Mailing Address - Country:US
Mailing Address - Phone:704-853-8227
Mailing Address - Fax:704-853-8272
Practice Address - Street 1:436 E LONG AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2516
Practice Address - Country:US
Practice Address - Phone:704-853-8227
Practice Address - Fax:704-853-8272
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2816101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102165Medicaid