Provider Demographics
NPI:1013217132
Name:CANNON, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-4610
Mailing Address - Country:US
Mailing Address - Phone:562-591-0011
Mailing Address - Fax:562-591-0071
Practice Address - Street 1:2008 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-4610
Practice Address - Country:US
Practice Address - Phone:562-591-0011
Practice Address - Fax:562-591-0071
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)