1508006883 NPI number — MRS. DESIREE KOPIL GANNON OTR/L

Table of content: MRS. DESIREE KOPIL GANNON OTR/L (NPI 1508006883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508006883 NPI number — MRS. DESIREE KOPIL GANNON OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANNON
Provider First Name:
DESIREE
Provider Middle Name:
KOPIL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOPIL
Provider Other First Name:
DESIREE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508006883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
131 SAFRAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDISON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08837-3205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-742-3749
Provider Business Mailing Address Fax Number:
732-709-3388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 SAFRAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDISON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08837-3205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-742-3749
Provider Business Practice Location Address Fax Number:
732-709-3388
Provider Enumeration Date:
02/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  008498-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225XP0200X , with the licence number: 46TR00098800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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