Provider Demographics
NPI:1376769141
Name:CANNON, SUZANNE R (LPC,LADC)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:R
Last Name:CANNON
Suffix:
Gender:F
Credentials:LPC,LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-2616
Mailing Address - Country:US
Mailing Address - Phone:405-350-1323
Mailing Address - Fax:
Practice Address - Street 1:110 S 4TH ST
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-2616
Practice Address - Country:US
Practice Address - Phone:405-350-1323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional