Provider Demographics
NPI:1477863504
Name:CANNON, MICHAEL DEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DEE
Last Name:CANNON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9629 HIGHWAY 270
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71602-9493
Mailing Address - Country:US
Mailing Address - Phone:870-489-0225
Mailing Address - Fax:
Practice Address - Street 1:9629 HIGHWAY 270
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71602-9493
Practice Address - Country:US
Practice Address - Phone:870-489-0225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR95-16 E - I103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling