Provider Demographics
NPI:1093928459
Name:CANNONWOLF, RITA MARIE (BA, T-ADC)
Entity Type:Individual
Prefix:MRS
First Name:RITA
Middle Name:MARIE
Last Name:CANNONWOLF
Suffix:
Gender:F
Credentials:BA, T-ADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 9TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2221
Mailing Address - Country:US
Mailing Address - Phone:320-763-3912
Mailing Address - Fax:320-763-6629
Practice Address - Street 1:222 9TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2221
Practice Address - Country:US
Practice Address - Phone:320-763-3912
Practice Address - Fax:320-763-6629
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility