Provider Demographics
NPI:1831315902
Name:CANNELL, JOHN EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:CANNELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11107 WURZBACH RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-2500
Mailing Address - Country:US
Mailing Address - Phone:210-690-0595
Mailing Address - Fax:
Practice Address - Street 1:11107 WURZBACH RD
Practice Address - Street 2:SUITE 401
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-2500
Practice Address - Country:US
Practice Address - Phone:210-690-0595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23429103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00B01AMedicare ID - Type Unspecified