Provider Demographics
NPI:1427105691
Name:CANNON, REBECCA L (MFT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:CANNON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 16TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1520
Mailing Address - Country:US
Mailing Address - Phone:510-357-5515
Mailing Address - Fax:510-357-5112
Practice Address - Street 1:13666 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2538
Practice Address - Country:US
Practice Address - Phone:510-357-5515
Practice Address - Fax:510-357-5112
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC15809106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist