Provider Demographics
NPI:1336883149
Name:CANNON, MARIAN BROWN
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:BROWN
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 N MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-1931
Mailing Address - Country:US
Mailing Address - Phone:252-217-1603
Mailing Address - Fax:
Practice Address - Street 1:505 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-5616
Practice Address - Country:US
Practice Address - Phone:252-212-5524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)