Provider Demographics
NPI:1205355260
Name:CANNON, SOPHIA AYANA (MCRC, CRC, LPC)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:AYANA
Last Name:CANNON
Suffix:
Gender:F
Credentials:MCRC, CRC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 TEASLEY LN # 103A
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-7946
Mailing Address - Country:US
Mailing Address - Phone:469-986-9629
Mailing Address - Fax:469-453-3193
Practice Address - Street 1:1332 TEASLEY LN # 103A
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-7946
Practice Address - Country:US
Practice Address - Phone:469-986-9629
Practice Address - Fax:469-453-3193
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00230818225C00000X, 101YM0800X
TX78375101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Multi-Specialty
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty