Provider Demographics
NPI:1265508311
Name:CANNON, STAR (CADC II, ICADC, MATS)
Entity Type:Individual
Prefix:
First Name:STAR
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:CADC II, ICADC, MATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 HERITAGE LN STE 187
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4922
Mailing Address - Country:US
Mailing Address - Phone:916-333-3800
Mailing Address - Fax:
Practice Address - Street 1:3637 MISSION AVE BLDG B
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2946
Practice Address - Country:US
Practice Address - Phone:916-485-4175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 171M00000X, 172V00000X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator