Provider Demographics
NPI:1912695271
Name:CANNON, MICHELLE R (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:R
Last Name:CANNON
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 SW 82ND ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9012
Mailing Address - Country:US
Mailing Address - Phone:580-510-2744
Mailing Address - Fax:
Practice Address - Street 1:1602 SW 82ND ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9012
Practice Address - Country:US
Practice Address - Phone:580-510-2744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11197101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health