Healthcare Provider Details

I. General information

NPI: 1992631162
Provider Name (Legal Business Name): DESIRAY M CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3062 E 91ST ST
CHICAGO IL
60617-4401
US

IV. Provider business mailing address

8051 S ESSEX AVE APT 1N
CHICAGO IL
60617-1264
US

V. Phone/Fax

Practice location:
  • Phone: 773-371-2900
  • Fax:
Mailing address:
  • Phone: 773-512-6171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150116837
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: