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General NPI Number Information
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NPI Number | 1700021839
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Entity Type | Individual
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Provider Name | EMILY ANNE VAN CANNON LCPC-C, LADC
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Gender | Female
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Dates
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Enumeration Date | 12/03/2008
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Last Update Date | 02/13/2015
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Provider Practice Location Address
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Address Line | 44 OAK ST
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City | PORTLAND
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State | ME
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Zip | 04101-3939
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Country | US
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Telephone | 207-756-4905
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Fax |
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Provider Business Mailing Address
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Address Line | 29 ALFRED ST
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City | SOUTH PORTLAND
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State | ME
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Zip | 04106-6302
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Country | US
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Telephone | 207-756-4905
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CAC4077
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LSX11430
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License Number State | ME
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | XL4264
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License Number State | ME
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Taxonomy #4
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LC4548
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License Number State | ME
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