Provider Demographics
NPI:1952850505
Name:CANNON, LARA CHRISTINE (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:CHRISTINE
Last Name:CANNON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 SW SHATTUCK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-3075
Mailing Address - Country:US
Mailing Address - Phone:503-477-7895
Mailing Address - Fax:
Practice Address - Street 1:9370 SW GREENBURG RD STE 413
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5427
Practice Address - Country:US
Practice Address - Phone:971-302-7374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5220101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional