MEDICARE: ANGEL DESOUZA CANNON LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	S. 1101314	OH

General Provider Information

NPI Number	:	1033461058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGEL DESOUZA CANNON LSW

Provider Business Mailing Address
First Line	:	PO BOX 21340
Second Line	:
City	:	SOUTH EUCLID
State	:	OH
Zip	:	44121-0340
Country	:	US
Telephone Number	:	216-308-5347
Fax Number	:

Provider Business Practice Location Address
First Line	:	5241 WILSON MILLS RD STE 24
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44143-2141
Country	:	US
Telephone Number	:	216-926-8879
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2012
Last Update Date	:	10/15/2012

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