MEDICARE: DR. JOHN T. CANNON PHD LMHP LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	372	NE
2	101YM0800X	Mental Health Counselor	1535	NE

General Provider Information

NPI Number	:	1700903143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN T. CANNON PHD LMHP LADC

Provider Business Mailing Address
First Line	:	16305 DECATUR CIR
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68118-2418
Country	:	US
Telephone Number	:	402-660-8049
Fax Number	:

Provider Business Practice Location Address
First Line	:	1045 N 115TH ST STE 205
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68154-4422
Country	:	US
Telephone Number	:	402-660-8049
Fax Number	:

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	11/08/2024

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