MEDICARE: FATINA CANNON LPC LAC

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	101YP2500X	Professional Counselor	11699	CO

General Provider Information

NPI Number	:	1124457304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FATINA CANNON LPC LAC

Provider Business Mailing Address
First Line	:	2115 W 32ND AVE UNIT 4
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80211-3449
Country	:	US
Telephone Number	:	720-526-0893
Fax Number	:

Provider Business Practice Location Address
First Line	:	2115 W 32ND AVE UNIT 4
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80211-3449
Country	:	US
Telephone Number	:	720-526-0893
Fax Number	:

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

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	02/22/2024

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