Provider Demographics
NPI:1447334198
Name:CANNON PSYCHOLOGICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:CANNON PSYCHOLOGICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:TRACY
Authorized Official - Last Name:GOODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-654-7848
Mailing Address - Street 1:1376 TIGER BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-2654
Mailing Address - Country:US
Mailing Address - Phone:864-654-7848
Mailing Address - Fax:864-654-5777
Practice Address - Street 1:1376 TIGER BLVD STE 210
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-2654
Practice Address - Country:US
Practice Address - Phone:864-654-7848
Practice Address - Fax:864-654-5777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC349103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0078Medicaid
SCPS0078Medicaid