Provider Demographics
NPI:1104060771
Name:MCGAHA, ANITA CANNON (SSP, LPA)
Entity type:Individual
Prefix:MS
First Name:ANITA
Middle Name:CANNON
Last Name:MCGAHA
Suffix:
Gender:F
Credentials:SSP, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5129 TULIP DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-1920
Mailing Address - Country:US
Mailing Address - Phone:910-818-1028
Mailing Address - Fax:
Practice Address - Street 1:596 EXECUTIVE PL STE 102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5189
Practice Address - Country:US
Practice Address - Phone:910-818-1028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC026103TS0200X
NC3577103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool