Provider Demographics
NPI:1477883668
Name:CANNON, MARY DALE (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DALE
Last Name:CANNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:DC
Other - Last Name:LAUTERBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2775 EXECUTIVE PARK NW
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-2763
Mailing Address - Country:US
Mailing Address - Phone:423-479-1171
Mailing Address - Fax:
Practice Address - Street 1:2775 EXECUTIVE PARK NW
Practice Address - Street 2:SUITE 1
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-2763
Practice Address - Country:US
Practice Address - Phone:423-479-9652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-11
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP2889103TB0200X
TN2889103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral