Provider Demographics
NPI:1396836110
Name:CANNON, THERESE A (LPCMH)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:A
Last Name:CANNON
Suffix:
Gender:F
Credentials:LPCMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 LARKSPUR RD
Mailing Address - Street 2:C/O COUNSELING RESOURCE ASSOCIATES, INC.
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-6863
Mailing Address - Country:US
Mailing Address - Phone:302-738-9963
Mailing Address - Fax:302-995-2121
Practice Address - Street 1:117 LARKSPUR RD
Practice Address - Street 2:C/O COUNSELING RESOURCE ASSOCIATES, INC.
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-6863
Practice Address - Country:US
Practice Address - Phone:302-738-9963
Practice Address - Fax:302-995-2121
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC -0000379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health