Provider Demographics
NPI:1588841530
Name:CANNON, MAURICE ANTONIO (LPC)
Entity Type:Individual
Prefix:MR
First Name:MAURICE
Middle Name:ANTONIO
Last Name:CANNON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 FARMWORTH TRL
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-7857
Mailing Address - Country:US
Mailing Address - Phone:757-892-0467
Mailing Address - Fax:
Practice Address - Street 1:2532 FARMWORTH TRL
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-7857
Practice Address - Country:US
Practice Address - Phone:757-892-0467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004268101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional