Provider Demographics
NPI:1114490877
Name:CANNON, BRENDA GAIL (BA IN PSYCHOLOGY)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:GAIL
Last Name:CANNON
Suffix:
Gender:F
Credentials:BA IN PSYCHOLOGY
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Mailing Address - Street 1:1301 SOUTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-5090
Mailing Address - Country:US
Mailing Address - Phone:919-637-8831
Mailing Address - Fax:
Practice Address - Street 1:3105 VICO TER
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-5951
Practice Address - Country:US
Practice Address - Phone:919-637-8831
Practice Address - Fax:919-890-5578
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-05
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC320600000X
NCMHL-092-898320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities