Healthcare Provider Details

I. General information

NPI: 1326005778
Provider Name (Legal Business Name): LISA MARIE CANNON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 NORTHGATE SQ
GREENSBURG PA
15601-1341
US

IV. Provider business mailing address

25 SHAWNEE DR
GREENSBURG PA
15601-4701
US

V. Phone/Fax

Practice location:
  • Phone: 724-832-0947
  • Fax: 724-832-0839
Mailing address:
  • Phone: 724-832-0947
  • Fax: 724-832-0839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS-006749-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: