Provider Demographics
NPI:1235423799
Name:CANNON, ROSE MARY (MSW)
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:MARY
Last Name:CANNON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7463 GERALD AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-3917
Mailing Address - Country:US
Mailing Address - Phone:586-292-0648
Mailing Address - Fax:
Practice Address - Street 1:1200 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2652
Practice Address - Country:US
Practice Address - Phone:248-658-1116
Practice Address - Fax:248-658-1120
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010572241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical