Provider Demographics
NPI:1043395759
Name:CANNON, KATHRYN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:A
Last Name:CANNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W SHAW AVE
Mailing Address - Street 2:SUITE 1-B
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3712
Mailing Address - Country:US
Mailing Address - Phone:559-226-6016
Mailing Address - Fax:559-226-6017
Practice Address - Street 1:1300 W SHAW AVE
Practice Address - Street 2:SUITE 1-B
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3712
Practice Address - Country:US
Practice Address - Phone:559-226-6016
Practice Address - Fax:559-226-6017
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14040103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent