Provider Demographics
NPI:1508479874
Name:LISA CANNON COUNSELING, LLC
Entity Type:Organization
Organization Name:LISA CANNON COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:765-267-8534
Mailing Address - Street 1:100 SAW MILL RD STE 3200
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5597
Mailing Address - Country:US
Mailing Address - Phone:765-267-8534
Mailing Address - Fax:765-374-0866
Practice Address - Street 1:100 SAW MILL RD STE 3200
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5597
Practice Address - Country:US
Practice Address - Phone:765-267-8534
Practice Address - Fax:765-374-0866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty