Healthcare Provider Details

I. General information

NPI: 1457742769
Provider Name (Legal Business Name): CHRISTOPHER CANON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2084 MAIN ST
WILLISBURG KY
40078-8199
US

IV. Provider business mailing address

4230 GLENS CREEK RD
WILLISBURG KY
40078-8168
US

V. Phone/Fax

Practice location:
  • Phone: 859-375-9200
  • Fax: 859-375-9202
Mailing address:
  • Phone: 859-797-6413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberKY-00837
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: