Provider Demographics
NPI:1033678107
Name:CANNON, MICHELLE RODIA
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RODIA
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RODIA
Other - Last Name:PASOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2440 TULARE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-2281
Mailing Address - Country:US
Mailing Address - Phone:559-443-4800
Mailing Address - Fax:
Practice Address - Street 1:2440 TULARE ST STE 200
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-2281
Practice Address - Country:US
Practice Address - Phone:559-443-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT118871106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist