Provider Demographics
NPI:1134975261
Name:CANNON, CHRISTIAN ALEXANDER
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:ALEXANDER
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 SANDY RUN
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-9790
Mailing Address - Country:US
Mailing Address - Phone:919-369-3997
Mailing Address - Fax:
Practice Address - Street 1:445 DOLLEY MADISON RD STE 100
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-5166
Practice Address - Country:US
Practice Address - Phone:336-649-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0212051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical