Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor |
NPI | 1003172461 |
---|---|
Provider Name | Michelle Cannon |
First Address | Melbourne, FL 32935-6340 |
Second Address | Melbourne, FL 32935-6340 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2012 |
Last Update Date | 10/04/2012 |