Provider Demographics
NPI:1932314861
Name:CANNON, PHOEBE GERALYN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PHOEBE
Middle Name:GERALYN
Last Name:CANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PHOEBE
Other - Middle Name:GERALYN
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:7000 E GENESEE ST BLDG C
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1131
Mailing Address - Country:US
Mailing Address - Phone:315-446-2110
Mailing Address - Fax:315-446-2110
Practice Address - Street 1:7000 E GENESEE ST BLDG C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1131
Practice Address - Country:US
Practice Address - Phone:315-446-2110
Practice Address - Fax:315-446-2110
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR052773101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDD1105Medicare ID - Type Unspecified