Provider Demographics
NPI:1649764424
Name:CANNON, MARY LOUISE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY LOUISE
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106R GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01966-1241
Mailing Address - Country:US
Mailing Address - Phone:978-546-9813
Mailing Address - Fax:
Practice Address - Street 1:106R GRANITE ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:MA
Practice Address - Zip Code:01966-1241
Practice Address - Country:US
Practice Address - Phone:978-546-9813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9767-PY-PR103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical