Provider Demographics
NPI:1881450161
Name:CANNON, KELLIE (LPC, MA, NCC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:LPC, MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 COMMONWEALTH DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1894
Mailing Address - Country:US
Mailing Address - Phone:602-908-8986
Mailing Address - Fax:
Practice Address - Street 1:1553 BRADFORD RD STE 102
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-4094
Practice Address - Country:US
Practice Address - Phone:757-453-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704015367101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional