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General NPI Number Information
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NPI Number | 1447334198
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Entity Type | Organization
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Legal Business Name | CANNON PSYCHOLOGICAL ASSOCIATES, PC
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Dates
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Enumeration Date | 10/25/2006
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Last Update Date | 09/06/2023
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Provider Practice Location Address
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Address Line | 1376 TIGER BLVD STE 210
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City | CLEMSON
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State | SC
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Zip | 29631-2654
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Country | US
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Telephone | 864-654-7848
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Fax | 864-654-5777
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Provider Business Mailing Address
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Address Line | 1376 TIGER BLVD STE 210
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City | CLEMSON
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State | SC
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Zip | 29631-2654
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Country | US
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Telephone | 864-654-7848
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Fax | 864-654-5777
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. ELIZABETH TRACY GOODE
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Credential |
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Telephone | 864-654-7848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 349
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License Number State | SC
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