Healthcare Provider Details

I. General information

NPI: 1932765732
Provider Name (Legal Business Name): CYNTHIA MARIE CANNER LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17826 NEW HAMPSHIRE AVE
ASHTON MD
20861-9781
US

IV. Provider business mailing address

PO BOX 1159
SEVERNA PARK MD
21146-8159
US

V. Phone/Fax

Practice location:
  • Phone: 800-491-5639
  • Fax: 301-774-3678
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP9326
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: