Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP1600X | Pastoral Counselor | 5016 | SC |
Y | 101YP2500X | Professional Counselor | 5016 | SC |
NPI | 1295961019 |
---|---|
Provider Name | Mr. Fred Reeves Cannon III |
First Address | Florence, SC 29505-3709 |
Second Address | Florence, SC 29505-3709 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2009 |
Last Update Date | 08/06/2009 |