Provider Demographics
NPI:1750615134
Name:CANNON, RENETTA DAWN (LSAA)
Entity type:Individual
Prefix:
First Name:RENETTA
Middle Name:DAWN
Last Name:CANNON
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 1ST ST NW STE 200
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2311
Mailing Address - Country:US
Mailing Address - Phone:505-224-9124
Mailing Address - Fax:505-247-9503
Practice Address - Street 1:600 1ST ST NW STE 200
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2311
Practice Address - Country:US
Practice Address - Phone:505-224-9124
Practice Address - Fax:505-247-9503
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0084181101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM71750274Medicaid