| Joseph Gannon, Ph.d. A Professional Psychology Corporation | |
|
4445 Eastgate Mall Pmb 843 Suite 200 San Diego CA 92121-1979 | |
| (858) 705-5439 | |
| (858) 771-1078 |
| Full Name | Joseph Gannon, Ph.d. A Professional Psychology Corporation |
|---|---|
| Speciality | Psychologist |
| Location | 4445 Eastgate Mall Pmb 843, San Diego, California |
| Authorized Official Name and Position | Joseph Patrick Gannon (PRESIDENT) |
| Authorized Official Contact | 8587055439 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Joseph Gannon, Ph.d. A Professional Psychology Corporation 4445 Eastgate Mall Pmb 843 Suite 200 San Diego CA 92121-1979 Ph: (858) 705-5439 | Joseph Gannon, Ph.d. A Professional Psychology Corporation 4445 Eastgate Mall Pmb 843 Suite 200 San Diego CA 92121-1979 Ph: (858) 705-5439 |
| NPI Number | 1245277227 |
|---|---|
| Provider Enumeration Date | 05/31/2006 |
| Last Update Date | 07/30/2022 |
| Certification Date | 07/30/2022 |
| Medicare PECOS PAC ID | 8022027010 |
|---|---|
| Medicare Enrollment ID | O20211108002833 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1245277227 | NPI | - | NPPES |
| OPL120340 | Other | CA | BLUE SHIELD PROVIDER IDEN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TB0200X | Psychologist - Cognitive & Behavioral | (* (Not Available)) | Primary |
| 103TC0700X | Psychologist - Clinical | PSY12034 (California) | Secondary |
| Provider Name | Joseph P Gannon |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1467440347 PECOS PAC ID: 7911916903 Enrollment ID: I20060420000350 |
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