MEDICARE: LYNN PERSICA CANNON LMSW

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	171M00000X	Case Manager/Care Coordinator	14381	LA
2	104100000X	Social Worker	14381	LA

General Provider Information

NPI Number	:	1265952873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNN PERSICA CANNON LMSW

Provider Business Mailing Address
First Line	:	8444 S ESSEN HEIGHTS CT
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-2217
Country	:	US
Telephone Number	:	225-771-8884
Fax Number	:	225-771-8884

Provider Business Practice Location Address
First Line	:	923 EXECUTIVE PARK AVE STE 12
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-2000
Country	:	US
Telephone Number	:	225-303-0212
Fax Number	:	225-355-1555

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

Provider Enumeration Date	:	06/24/2017
Last Update Date	:	09/12/2018

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