Provider Demographics
NPI:1548269236
Name:GANNON, KAREN RENE (PSYD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:RENE
Last Name:GANNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9031 CROSS PARK DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4602
Mailing Address - Country:US
Mailing Address - Phone:865-545-4592
Mailing Address - Fax:
Practice Address - Street 1:9031 CROSS PARK DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4602
Practice Address - Country:US
Practice Address - Phone:865-545-4592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2010-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP2460103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3585339Medicaid
TN3585339Medicaid