MEDICARE: CANNONIER PSYCHOLOGICAL CENTER LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1356002331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANNONIER PSYCHOLOGICAL CENTER LLC

Provider Business Mailing Address
First Line	:	318 PINHURST DR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-3696
Country	:	US
Telephone Number	:	786-717-0008
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 NORTHSIDE DR NW STE A7
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-2695
Country	:	US
Telephone Number	:	678-383-7393
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SHAREECE CANNONIER
Credential	:	PSYD
Telephone Number	:	786-717-0008

Provider Enumeration Date	:	01/03/2022
Last Update Date	:	01/03/2022

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