Healthcare Provider Details

I. General information

NPI: 1295961019
Provider Name (Legal Business Name): FRED REEVES CANNON III M.A., LPC, BCPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 3RD LOOP RD
FLORENCE SC
29505-3709
US

IV. Provider business mailing address

1140 3RD LOOP RD
FLORENCE SC
29505-3709
US

V. Phone/Fax

Practice location:
  • Phone: 843-662-2021
  • Fax: 843-662-2021
Mailing address:
  • Phone: 843-662-2021
  • Fax: 843-662-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number5016
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5016
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: