Provider Demographics
NPI:1134420342
Name:CANNON, MARCUS ALDEN (LMFT)
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:ALDEN
Last Name:CANNON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 SPRUCE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2464
Mailing Address - Country:US
Mailing Address - Phone:951-315-2693
Mailing Address - Fax:
Practice Address - Street 1:1405 SPRUCE ST
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2464
Practice Address - Country:US
Practice Address - Phone:951-315-2693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82999106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist