1114490877 NPI number — MS. BRENDA GAIL CANNON BA IN PSYCHOLOGY

Table of content: MS. BRENDA GAIL CANNON BA IN PSYCHOLOGY (NPI 1114490877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114490877 NPI number — MS. BRENDA GAIL CANNON BA IN PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANNON
Provider First Name:
BRENDA
Provider Middle Name:
GAIL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BA IN PSYCHOLOGY
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114490877
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 SOUTHGATE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27610-5090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-637-8831
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3105 VICO TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27610-5951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-637-8831
Provider Business Practice Location Address Fax Number:
919-890-5578
Provider Enumeration Date:
01/05/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320600000X , with the licence number: MHL-092-898 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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