Provider Demographics
NPI:1538806096
Name:SOURADA CANNON, CLARISSA BREANNE (MA, LPC,NCC)
Entity type:Individual
Prefix:MS
First Name:CLARISSA
Middle Name:BREANNE
Last Name:SOURADA CANNON
Suffix:
Gender:F
Credentials:MA, LPC,NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550-4960
Mailing Address - Country:US
Mailing Address - Phone:760-504-3099
Mailing Address - Fax:
Practice Address - Street 1:820 16TH ST
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550-4960
Practice Address - Country:US
Practice Address - Phone:760-504-3099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82764101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor