=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235643784
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER ANNE CANNON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2017
-----------------------------------------------------
Last Update Date | 07/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10159 MISSION GORGE RD
-----------------------------------------------------
City | SANTEE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92071-3857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-579-0947
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10159 MISSION GORGE RD
-----------------------------------------------------
City | SANTEE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92071-3857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-227-1385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------