MEDICARE: DR. TAMARA CANNON PHD

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	103T00000X	Psychologist	37774	TX

General Provider Information

NPI Number	:	1558875302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAMARA CANNON PHD

Provider Business Mailing Address
First Line	:	4059 MARBLE HILL RD
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75034-8458
Country	:	US
Telephone Number	:	713-724-1755
Fax Number	:

Provider Business Practice Location Address
First Line	:	1340 PRUDENTIAL DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-4115
Country	:	US
Telephone Number	:	972-646-1665
Fax Number	:

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

Provider Enumeration Date	:	11/30/2017
Last Update Date	:	02/24/2020

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Directions to “ DR. TAMARA CANNON PHD” Practice Location

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