Provider Demographics
NPI:1578031852
Name:CANNELLA, KEVIN (LPCC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CANNELLA
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-4626
Mailing Address - Country:US
Mailing Address - Phone:410-913-5989
Mailing Address - Fax:
Practice Address - Street 1:3050 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3154
Practice Address - Country:US
Practice Address - Phone:410-913-5989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0016287101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health