Provider Demographics
NPI:1033461058
Name:CANNON, ANGEL DESOUZA (LSW)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:DESOUZA
Last Name:CANNON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21340
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-0340
Mailing Address - Country:US
Mailing Address - Phone:216-308-5347
Mailing Address - Fax:
Practice Address - Street 1:5241 WILSON MILLS RD STE 24
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44143-2141
Practice Address - Country:US
Practice Address - Phone:216-926-8879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS. 1101314104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker