MEDICARE: MRS. RENEE CANNON M.A., L.P.C.

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	6401007746	MI

General Provider Information

NPI Number	:	1649341850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RENEE CANNON M.A., L.P.C.

Provider Business Mailing Address
First Line	:	1279 MULBERRY ST
Second Line	:
City	:	MOUNT CLEMENS
State	:	MI
Zip	:	48043-3003
Country	:	US
Telephone Number	:	586-469-9609
Fax Number	:

Provider Business Practice Location Address
First Line	:	36975 UTICA RD
Second Line	:	SUITE 104
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48036-1685
Country	:	US
Telephone Number	:	586-226-3440
Fax Number	:	586-226-3740

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

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	06/10/2009

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