Healthcare Provider Details

I. General information

NPI: 1659915296
Provider Name (Legal Business Name): MICHAEL KANNER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 WOODSTOCK RD
ROSWELL GA
30075-3559
US

IV. Provider business mailing address

41 WOODSTOCK RD
ROSWELL GA
30075-3559
US

V. Phone/Fax

Practice location:
  • Phone: 770-580-0036
  • Fax:
Mailing address:
  • Phone: 770-580-0036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC013026
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberLD004005
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: