Provider Demographics
NPI:1376777110
Name:CANNON, LAURELYN DEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURELYN
Middle Name:DEE
Last Name:CANNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LYN
Other - Middle Name:D
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:4618 CONSTITUTION AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-1005
Mailing Address - Country:US
Mailing Address - Phone:719-596-1058
Mailing Address - Fax:
Practice Address - Street 1:4618 CONSTITUTION AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-1005
Practice Address - Country:US
Practice Address - Phone:719-596-1058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC #196103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist