MEDICARE: KEVIN CANNELLA LPCC

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	101YM0800X	Mental Health Counselor	LPCC.0016287	CO

General Provider Information

NPI Number	:	1578031852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN CANNELLA LPCC

Provider Business Mailing Address
First Line	:	2275 SPRUCE ST
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80302-4626
Country	:	US
Telephone Number	:	410-913-5989
Fax Number	:

Provider Business Practice Location Address
First Line	:	3050 BROADWAY ST
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80304-3154
Country	:	US
Telephone Number	:	410-913-5989
Fax Number	:

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

Provider Enumeration Date	:	11/05/2018
Last Update Date	:	11/05/2018

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