Provider Demographics
NPI:1184206617
Name:CANNON, AUBREY
Entity Type:Individual
Prefix:
First Name:AUBREY
Middle Name:
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 1:12801 FLUSHING MEADOWS DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1829
Mailing Address - Country:US
Mailing Address - Phone:314-907-0216
Mailing Address - Fax:
Practice Address - Street 1:12801 FLUSHING MEADOWS DR STE 110
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1829
Practice Address - Country:US
Practice Address - Phone:314-907-0216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021037534101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty