Provider Demographics
NPI:1407058001
Name:CANNON, JOAN (LMFT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 W 116TH ST
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-9311
Mailing Address - Country:US
Mailing Address - Phone:317-873-8140
Mailing Address - Fax:
Practice Address - Street 1:4715 W 116TH ST
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-9311
Practice Address - Country:US
Practice Address - Phone:317-873-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001572A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN35001572AOtherLMFT LICENSE #