Provider Demographics
NPI:1437673274
Name:CANNON, DANIELLE ELAINE (LCSW)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:ELAINE
Last Name:CANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14615 REAGAN CT
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8327
Mailing Address - Country:US
Mailing Address - Phone:208-661-2645
Mailing Address - Fax:
Practice Address - Street 1:950 W IRONWOOD DR STE 6
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2644
Practice Address - Country:US
Practice Address - Phone:208-661-2645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-315451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical