Provider Demographics
NPI:1538462312
Name:GANNON, STEPHEN MICHAEL (LADC1)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:GANNON
Suffix:
Gender:M
Credentials:LADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 VENUS WAY
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03076-2126
Mailing Address - Country:US
Mailing Address - Phone:617-529-5511
Mailing Address - Fax:
Practice Address - Street 1:1010 VARNUM AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-1915
Practice Address - Country:US
Practice Address - Phone:617-529-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2025-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
MA22822101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251B00000XAgenciesCase Management