Provider Demographics
NPI:1760731178
Name:CANNON, HEATHER (LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:MACVEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:758 NW RAINBOW ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8309
Mailing Address - Country:US
Mailing Address - Phone:772-834-4872
Mailing Address - Fax:
Practice Address - Street 1:758 NW RAINBOW ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8309
Practice Address - Country:US
Practice Address - Phone:772-834-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2023-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW125121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical