Provider Demographics
NPI:1720534464
Name:CANNON, ELIZABETH (MS, CFY-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:MS, CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19651 PIKE 266
Mailing Address - Street 2:
Mailing Address - City:EOLIA
Mailing Address - State:MO
Mailing Address - Zip Code:63344
Mailing Address - Country:US
Mailing Address - Phone:573-999-4783
Mailing Address - Fax:
Practice Address - Street 1:610 LOWRY STREET
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363
Practice Address - Country:US
Practice Address - Phone:217-285-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.003931235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist