Provider Demographics
NPI:1225738792
Name:CANNON, CHARLES (EDS, NCSP, LMHCA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:EDS, NCSP, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12124 SE 292ND ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-2075
Mailing Address - Country:US
Mailing Address - Phone:602-377-6751
Mailing Address - Fax:
Practice Address - Street 1:312 11TH AVE W STE 201
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-5326
Practice Address - Country:US
Practice Address - Phone:425-576-1817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health