Provider Demographics
NPI:1376019851
Name:CANNON, ALEXIS HELEN (RBT)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:HELEN
Last Name:CANNON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61-264 KAMEHAMEHA HWY APT A
Mailing Address - Street 2:
Mailing Address - City:HALEIWA
Mailing Address - State:HI
Mailing Address - Zip Code:96712-1309
Mailing Address - Country:US
Mailing Address - Phone:843-655-2641
Mailing Address - Fax:
Practice Address - Street 1:61-264 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:HALEIWA
Practice Address - State:HI
Practice Address - Zip Code:96712-1309
Practice Address - Country:US
Practice Address - Phone:843-655-2641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-18-68725106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician