Provider Demographics
NPI:1205969623
Name:CANNON, TUCKER CROXALL (LCSW)
Entity type:Individual
Prefix:MR
First Name:TUCKER
Middle Name:CROXALL
Last Name:CANNON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MAIN ST. SUITE 4091
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92661-9998
Mailing Address - Country:US
Mailing Address - Phone:949-244-9982
Mailing Address - Fax:
Practice Address - Street 1:2046 ALLEN AVE RM 100
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-3424
Practice Address - Country:US
Practice Address - Phone:626-660-9419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA287071041C0700X, 1041S0200X
CA187841041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical