Provider Demographics
NPI:1548004807
Name:CANNON, BRITTANY
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 STERLING DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-7566
Mailing Address - Country:US
Mailing Address - Phone:843-544-5332
Mailing Address - Fax:
Practice Address - Street 1:110 YE OLDE KINGS HWY
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-4384
Practice Address - Country:US
Practice Address - Phone:843-663-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8954101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional