Provider Demographics
NPI:1700021839
Name:VAN CANNON, EMILY ANNE (LCPC-C, LADC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ANNE
Last Name:VAN CANNON
Suffix:
Gender:F
Credentials:LCPC-C, LADC
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ANNE
Other - Last Name:VAN STRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC-C, LADC
Mailing Address - Street 1:29 ALFRED ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6302
Mailing Address - Country:US
Mailing Address - Phone:207-756-4905
Mailing Address - Fax:
Practice Address - Street 1:44 OAK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3939
Practice Address - Country:US
Practice Address - Phone:207-756-4905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC4077101YA0400X
MELSX11430104100000X
MEXL4264101YM0800X
MELC4548101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker