Provider Demographics
NPI:1598049694
Name:CANNON, KIERA (LLPC, MS-MHC)
Entity Type:Individual
Prefix:
First Name:KIERA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:LLPC, MS-MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8965 CROSLEY
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1535
Mailing Address - Country:US
Mailing Address - Phone:313-377-5725
Mailing Address - Fax:
Practice Address - Street 1:8965 CROSLEY
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1535
Practice Address - Country:US
Practice Address - Phone:313-377-5725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012433101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health