Provider Demographics
NPI:1063095602
Name:CANNON SPEECH SERVICES LLC
Entity type:Organization
Organization Name:CANNON SPEECH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:830-315-6400
Mailing Address - Street 1:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:INGRAM
Mailing Address - State:TX
Mailing Address - Zip Code:78025-0643
Mailing Address - Country:US
Mailing Address - Phone:214-354-5201
Mailing Address - Fax:
Practice Address - Street 1:327 EARL GARRETT ST STE 108
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-4500
Practice Address - Country:US
Practice Address - Phone:830-315-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANNON SPEECH SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty