MEDICARE: KAREN CANNON

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	178.011376	IL
2	101YP2500X	Professional Counselor	180.012513	IL

General Provider Information

NPI Number	:	1568814895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN CANNON

Provider Business Mailing Address
First Line	:	5113 S HARPER AVE # 2C
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4119
Country	:	US
Telephone Number	:	312-521-0866
Fax Number	:

Provider Business Practice Location Address
First Line	:	5113 S HARPER AVE # 2C
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4119
Country	:	US
Telephone Number	:	312-521-0866
Fax Number	:

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

Provider Enumeration Date	:	07/11/2016
Last Update Date	:	10/17/2022

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Directions to “ KAREN CANNON ” Practice Location

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