Provider Demographics
NPI:1942604715
Name:CANNON, PAMELA (LPC-S)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:LPC-S
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 929
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-0929
Mailing Address - Country:US
Mailing Address - Phone:318-255-5753
Mailing Address - Fax:318-242-4698
Practice Address - Street 1:902 DEVILLE LN
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-6313
Practice Address - Country:US
Practice Address - Phone:318-255-5753
Practice Address - Fax:318-242-4698
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1952101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional