MEDICARE: PHILIP ANDREW CANNON MS, MFT-I

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	106H00000X	Marriage & Family Therapist	2318	TN

General Provider Information

NPI Number	:	1659152619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP ANDREW CANNON MS, MFT-I

Provider Business Mailing Address
First Line	:	5144 CREEK BEND CIR NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312-4109
Country	:	US
Telephone Number	:	423-284-5786
Fax Number	:

Provider Business Practice Location Address
First Line	:	1441 GUTHRIE DR NW STE 106
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37311-3642
Country	:	US
Telephone Number	:	423-284-5786
Fax Number	:

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

Provider Enumeration Date	:	10/06/2023
Last Update Date	:	10/06/2023

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