Provider Demographics
NPI:1144851163
Name:CANNON, CHRISTIAN (LMHC)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 S HALIFAX AVE APT 19
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-4459
Mailing Address - Country:US
Mailing Address - Phone:386-295-5872
Mailing Address - Fax:
Practice Address - Street 1:144 S HALIFAX AVE APT 19
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-4459
Practice Address - Country:US
Practice Address - Phone:386-295-5872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health