Provider Demographics
NPI:1467335307
Name:CANNON, AMADEUS YVEZ
Entity type:Individual
Prefix:
First Name:AMADEUS
Middle Name:YVEZ
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 ELDEN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4851
Mailing Address - Country:US
Mailing Address - Phone:703-496-4371
Mailing Address - Fax:
Practice Address - Street 1:131 ELDEN ST STE 302
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4851
Practice Address - Country:US
Practice Address - Phone:703-496-4371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician