Healthcare Provider Details

I. General information

NPI: 1629190368
Provider Name (Legal Business Name): MARIE ELIZABETH CANNON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18970 MOUNT CIMARRON ST
FOUNTAIN VALLEY CA
92708-7313
US

IV. Provider business mailing address

18970 MOUNT CIMARRON ST
FOUNTAIN VALLEY CA
92708-7313
US

V. Phone/Fax

Practice location:
  • Phone: 833-851-1600
  • Fax:
Mailing address:
  • Phone: 775-762-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7180-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: