Basic Information
| Provider Information | |||||||||
| NPI: | 1689959058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1726 SE 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545224749 | ||||||||
| FaxNumber: | 9545229357 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 SE 18TH CT | ||||||||
| Address2: | |||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545224749 | ||||||||
| FaxNumber: | 9545229357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2011 | ||||||||
| LastUpdateDate: | 10/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW7856 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.