Provider Demographics
NPI:1558875302
Name:CANNON, TAMARA (PHD)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4059 MARBLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-8458
Mailing Address - Country:US
Mailing Address - Phone:713-724-1755
Mailing Address - Fax:
Practice Address - Street 1:1340 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-4115
Practice Address - Country:US
Practice Address - Phone:972-646-1665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37774103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist