Provider Demographics
NPI:1265084263
Name:CANNON, CHRISTINA L (RADT)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:L
Last Name:CANNON
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2577 NE COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7752
Mailing Address - Country:US
Mailing Address - Phone:541-332-7500
Mailing Address - Fax:541-322-7565
Practice Address - Street 1:63311 JAMISON ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-8288
Practice Address - Country:US
Practice Address - Phone:541-332-7500
Practice Address - Fax:541-322-7565
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CAR1353740719101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)