Provider Demographics
NPI:1659915296
Name:KANNER, MICHAEL (LPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KANNER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 WOODSTOCK RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3559
Mailing Address - Country:US
Mailing Address - Phone:770-580-0036
Mailing Address - Fax:
Practice Address - Street 1:41 WOODSTOCK RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3559
Practice Address - Country:US
Practice Address - Phone:770-580-0036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004005133VN1201X
LPC013026101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Multi-Specialty