Provider Demographics
NPI:1225676034
Name:CANNON, GLYNN EDWARD (LPC)
Entity Type:Individual
Prefix:MR
First Name:GLYNN
Middle Name:EDWARD
Last Name:CANNON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 SLAUGHTER RD STE E
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-5901
Mailing Address - Country:US
Mailing Address - Phone:520-275-1175
Mailing Address - Fax:
Practice Address - Street 1:1230 SLAUGHTER RD STE E
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-5901
Practice Address - Country:US
Practice Address - Phone:256-694-0788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4546101YM0800X
ALC2482A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor