Healthcare Provider Details

I. General information

NPI: 1093359408
Provider Name (Legal Business Name): REBECCA H CANNON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 MAINE ST STE BH1
BRUNSWICK ME
04011-3310
US

IV. Provider business mailing address

329 MAINE ST STE BH1
BRUNSWICK ME
04011-3310
US

V. Phone/Fax

Practice location:
  • Phone: 844-292-0111
  • Fax: 207-373-9418
Mailing address:
  • Phone: 844-292-0111
  • Fax: 207-373-9418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC11553
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: