Healthcare Provider Details

I. General information

NPI: 1073437877
Provider Name (Legal Business Name): GLINDA MARIE CANNON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

617 1ST ST SE
MOULTRIE GA
31768-5507
US

IV. Provider business mailing address

2993 OLD ALBANY RD
DOERUN GA
31744-5313
US

V. Phone/Fax

Practice location:
  • Phone: 229-456-2864
  • Fax:
Mailing address:
  • Phone: 229-456-2864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC017191
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: