Provider Demographics
NPI:1306867064
Name:CANNON, TERESA MAE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:MAE
Last Name:CANNON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 RAVENWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802
Mailing Address - Country:US
Mailing Address - Phone:979-680-0361
Mailing Address - Fax:979-693-2962
Practice Address - Street 1:1605 ROCK PRAIRIE RD STE 212
Practice Address - Street 2:BRYAN COLLEGE STATION OUTPATIENT CLINIC
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8358
Practice Address - Country:US
Practice Address - Phone:979-680-0361
Practice Address - Fax:979-693-2962
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15534104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker