Provider Demographics
NPI:1326005778
Name:CANNON, LISA MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:CANNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 SHAWNEE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-4701
Mailing Address - Country:US
Mailing Address - Phone:724-832-0947
Mailing Address - Fax:724-832-0839
Practice Address - Street 1:1 NORTHGATE SQ
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-1341
Practice Address - Country:US
Practice Address - Phone:724-832-0947
Practice Address - Fax:724-832-0839
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-006749-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA753497Medicare ID - Type Unspecified