Provider Demographics
NPI:1164721635
Name:CANNON, DONNA MICHELLE
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MICHELLE
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25321 LINDA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5310
Mailing Address - Country:US
Mailing Address - Phone:562-244-0504
Mailing Address - Fax:
Practice Address - Street 1:25321 LINDA VISTA DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5310
Practice Address - Country:US
Practice Address - Phone:562-244-0504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
103K00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator