Provider Demographics
NPI:1164593661
Name:CANNON, MARY ELIZABETH (LMHC,CRC,CASAC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:CANNON
Suffix:
Gender:F
Credentials:LMHC,CRC,CASAC
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC,CRC,CASAC
Mailing Address - Street 1:PO BOX 1300
Mailing Address - Street 2:69 SURFSIDE AVE
Mailing Address - City:MONTAUK
Mailing Address - State:NY
Mailing Address - Zip Code:11954-0896
Mailing Address - Country:US
Mailing Address - Phone:631-238-5060
Mailing Address - Fax:631-238-5060
Practice Address - Street 1:69 SURFSIDE AVE
Practice Address - Street 2:
Practice Address - City:MONTAUK
Practice Address - State:NY
Practice Address - Zip Code:11954-0896
Practice Address - Country:US
Practice Address - Phone:631-238-5060
Practice Address - Fax:631-238-5060
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002860-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health