Provider Demographics
NPI:1659040178
Name:CANNON, WILLIAM CHASE
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CHASE
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3860
Mailing Address - Country:US
Mailing Address - Phone:781-423-5215
Mailing Address - Fax:
Practice Address - Street 1:5 HIGH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3860
Practice Address - Country:US
Practice Address - Phone:781-423-5215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker