Provider Demographics
NPI:1154993418
Name:CANNON, CAROL W (LICSW)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:W
Last Name:CANNON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 N BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36603-5827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 N BAYOU ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36603-5827
Practice Address - Country:US
Practice Address - Phone:251-690-8158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1064C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL276301Medicaid
AL275693Medicaid
AL276253Medicaid