Provider Demographics
NPI:1477217172
Name:CANNON, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3736 EXECUTIVE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2360
Mailing Address - Country:US
Mailing Address - Phone:706-842-5330
Mailing Address - Fax:706-842-5340
Practice Address - Street 1:1084 LAKE MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2821
Practice Address - Country:US
Practice Address - Phone:706-842-5330
Practice Address - Fax:706-842-5340
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-21-190666106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician