Provider Demographics
NPI:1922759935
Name:CANNON, BONNI ROCHELLE
Entity Type:Individual
Prefix:
First Name:BONNI
Middle Name:ROCHELLE
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2651 WHITEWAY RD APT 4
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3656
Mailing Address - Country:US
Mailing Address - Phone:419-807-7263
Mailing Address - Fax:
Practice Address - Street 1:2651 WHITEWAY RD APT 4
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3656
Practice Address - Country:US
Practice Address - Phone:419-807-7263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH179476251B00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251B00000XAgenciesCase Management