Provider Demographics
NPI:1982305009
Name:CANNON, BRUCE A
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6193 PORTERIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2626
Mailing Address - Country:US
Mailing Address - Phone:734-604-3454
Mailing Address - Fax:
Practice Address - Street 1:496 W ANN ARBOR TRL STE 106
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6262
Practice Address - Country:US
Practice Address - Phone:734-335-8799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022372101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health