Provider Demographics
NPI:1528396447
Name:CANNON, KIMBERLY M (MSW, LISW-CP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:CANNON
Suffix:
Gender:F
Credentials:MSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:SC
Mailing Address - Zip Code:29706-1524
Mailing Address - Country:US
Mailing Address - Phone:803-581-9079
Mailing Address - Fax:
Practice Address - Street 1:223 E MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4571
Practice Address - Country:US
Practice Address - Phone:803-328-9600
Practice Address - Fax:803-329-7141
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC99251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical