Provider Demographics
NPI:1275175341
Name:CANNON, FANTA FANTEY (BCBA)
Entity Type:Individual
Prefix:MS
First Name:FANTA
Middle Name:FANTEY
Last Name:CANNON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 TIFFANY S
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1977
Mailing Address - Country:US
Mailing Address - Phone:330-629-2955
Mailing Address - Fax:
Practice Address - Street 1:1051 TIFFANY S
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-1977
Practice Address - Country:US
Practice Address - Phone:330-629-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty