Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | R#019571 | NY |
N | 103T00000X | Psychologist | R#019571 | NY |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 0190571 | NY |
N | 103G00000X | Clinical Psychologist | 0190571 | NY |
N | 103TC0700X | Clinical Psychologist | 0190571 | NY |
N | 103TF0000X | Family Psychologist | 0190571 | NY |
N | 103TF0200X | Forensic Psychologist | 0190571 | NY |
N | 103TP2701X | Group Psychotherapist | 019571 | NY |
Y | 1041C0700X | Clinical Social Worker | 0190571 | NY |
NPI | 1225003379 |
---|---|
Provider Name | Ms. Jill Cannon |
First Address | Katonah, NY 10536-3430 |
Second Address | Katonah, NY 10536-3430 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2006 |
Last Update Date | 23/10/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
135497 | VALUE OPTIONS (01) | |
140019057NY01 | ANTHEM (01) |