Provider Demographics
NPI:1023778636
Name:HANEBUTH, CANNON LEIGH (PT,DPT)
Entity type:Individual
Prefix:
First Name:CANNON
Middle Name:LEIGH
Last Name:HANEBUTH
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 TYLERTON CIR
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-7901
Mailing Address - Country:US
Mailing Address - Phone:847-650-0978
Mailing Address - Fax:
Practice Address - Street 1:21 LOWER RAGSDALE DR
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5827
Practice Address - Country:US
Practice Address - Phone:831-264-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2305214431225100000X
CA301734225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist