Provider Demographics
NPI:1902780463
Name:VAN CANON, WESLEY JAMES
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:JAMES
Last Name:VAN CANON
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 1:2712 BUCKHORN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-4201
Mailing Address - Country:US
Mailing Address - Phone:863-258-9098
Mailing Address - Fax:
Practice Address - Street 1:13424 FORT KING RD
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5214
Practice Address - Country:US
Practice Address - Phone:352-437-3559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-439381106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician