Provider Demographics
NPI:1700343530
Name:CANNON, MARY ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:CANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 MONTAGUE COUNTY DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-1609
Mailing Address - Country:US
Mailing Address - Phone:254-383-3421
Mailing Address - Fax:
Practice Address - Street 1:4203 WOODCOCK DR STE 216
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-1312
Practice Address - Country:US
Practice Address - Phone:210-564-9116
Practice Address - Fax:210-564-9087
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX583511041C0700X, 1041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator