Provider Demographics
NPI:1609354711
Name:CANNON, BONNIE L (LICSW)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:L
Last Name:CANNON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 DUNDEE PARK DR STE 301
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3725
Mailing Address - Country:US
Mailing Address - Phone:978-396-9866
Mailing Address - Fax:
Practice Address - Street 1:2 DUNDEE PARK DR STE 301
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3725
Practice Address - Country:US
Practice Address - Phone:978-396-9866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW1199301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical