Provider Demographics
NPI:1154579977
Name:CANNON, CARRIE ELLA (MA)
Entity type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:ELLA
Last Name:CANNON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:KARI
Other - Middle Name:ELLA
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:571 SAGINAW EDDY RD
Mailing Address - Street 2:
Mailing Address - City:DONALDSON
Mailing Address - State:AR
Mailing Address - Zip Code:71941-8060
Mailing Address - Country:US
Mailing Address - Phone:501-515-8656
Mailing Address - Fax:
Practice Address - Street 1:1615 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2233
Practice Address - Country:US
Practice Address - Phone:501-332-5236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3455-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical