Provider Demographics
NPI:1568814895
Name:CANNON, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
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 1:5113 S HARPER AVE # 2C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4119
Mailing Address - Country:US
Mailing Address - Phone:312-521-0866
Mailing Address - Fax:
Practice Address - Street 1:5113 S HARPER AVE # 2C
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4119
Practice Address - Country:US
Practice Address - Phone:312-521-0866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011376101YP2500X
IL180.012513101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional