Provider Demographics
NPI:1770592339
Name:CANNON, DALE SHERMAN (PHD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:SHERMAN
Last Name:CANNON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CHIPETA WAY
Mailing Address - Street 2:SUITE 221
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1270
Mailing Address - Country:US
Mailing Address - Phone:801-581-5864
Mailing Address - Fax:801-585-5194
Practice Address - Street 1:410 CHIPETA WAY
Practice Address - Street 2:SUITE 221
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1270
Practice Address - Country:US
Practice Address - Phone:801-581-5864
Practice Address - Fax:801-585-5194
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1058162501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical