Healthcare Provider Details

I. General information

NPI: 1366140295
Provider Name (Legal Business Name): MARISSA CANNON RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 S JONES BLVD STE 3465
LAS VEGAS NV
89107-2623
US

IV. Provider business mailing address

3652 CALICO COVE CT
LAS VEGAS NV
89147-6801
US

V. Phone/Fax

Practice location:
  • Phone: 702-430-7660
  • Fax: 702-430-7660
Mailing address:
  • Phone: 702-521-1517
  • Fax: 702-430-7660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA0956
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: