Healthcare Provider Details

I. General information

NPI: 1477863504
Provider Name (Legal Business Name): MICHAEL DEE CANNON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9629 HIGHWAY 270
PINE BLUFF AR
71602-9493
US

IV. Provider business mailing address

9629 HIGHWAY 270
PINE BLUFF AR
71602-9493
US

V. Phone/Fax

Practice location:
  • Phone: 870-489-0225
  • Fax:
Mailing address:
  • Phone: 870-489-0225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number95-16 E - I
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: