Provider Demographics
NPI:1447645148
Name:CANNON, COURTNEY MICHELLE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MICHELLE
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 WOODLANE RD
Mailing Address - Street 2:
Mailing Address - City:WESTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-3804
Mailing Address - Country:US
Mailing Address - Phone:609-267-5928
Mailing Address - Fax:
Practice Address - Street 1:1611 HIDER LN
Practice Address - Street 2:
Practice Address - City:CLEMENTON
Practice Address - State:NJ
Practice Address - Zip Code:08021-4825
Practice Address - Country:US
Practice Address - Phone:856-537-2309
Practice Address - Fax:856-227-2184
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health