Provider Demographics
NPI:1851176069
Name:CANNON, DAVE (LPC)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14615 REAGAN CT
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8327
Mailing Address - Country:US
Mailing Address - Phone:208-661-0553
Mailing Address - Fax:
Practice Address - Street 1:704 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7559
Practice Address - Country:US
Practice Address - Phone:208-661-0553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health