Provider Demographics
NPI:1316144819
Name:CANNON, CALLEEN ANN (LCPC)
Entity type:Individual
Prefix:
First Name:CALLEEN
Middle Name:ANN
Last Name:CANNON
Suffix:
Gender:
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4205
Mailing Address - Country:US
Mailing Address - Phone:208-295-9430
Mailing Address - Fax:208-213-5765
Practice Address - Street 1:845 W CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-4205
Practice Address - Country:US
Practice Address - Phone:208-295-9430
Practice Address - Fax:208-213-5765
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4273101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional