Provider Demographics
NPI:1871782813
Name:CANNON, TERESA LEE (AUD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LEE
Last Name:CANNON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 TODT HILL RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4528
Mailing Address - Country:US
Mailing Address - Phone:718-816-1952
Mailing Address - Fax:718-816-5118
Practice Address - Street 1:2670 N COLUMBUS ST STE B
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-8408
Practice Address - Country:US
Practice Address - Phone:740-654-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001287-1231H00000X
OHA.02265231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM04871Medicare PIN