Provider Demographics
NPI:1851442719
Name:CANNON, BETTY KAY (LPC)
Entity Type:Individual
Prefix:MS
First Name:BETTY
Middle Name:KAY
Last Name:CANNON
Suffix:
Gender:F
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:PO BOX 740152
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374-0152
Mailing Address - Country:US
Mailing Address - Phone:214-537-9297
Mailing Address - Fax:214-343-3321
Practice Address - Street 1:10910 LISTI DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-2952
Practice Address - Country:US
Practice Address - Phone:214-537-9297
Practice Address - Fax:214-343-3321
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16220101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNS162122OtherID VALUE OPTIONS