Provider Demographics
NPI:1225581887
Name:CANNON, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 SMITH RD APT 2
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-4231
Mailing Address - Country:US
Mailing Address - Phone:216-338-2901
Mailing Address - Fax:
Practice Address - Street 1:4330 SMITH RD APT 2
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212-4231
Practice Address - Country:US
Practice Address - Phone:216-338-2901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst