Provider Demographics
NPI:1487618211
Name:CANNON, JOHN ROY (LPCMH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROY
Last Name:CANNON
Suffix:
Gender:M
Credentials:LPCMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 LARKSPUR RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-6863
Mailing Address - Country:US
Mailing Address - Phone:302-738-9963
Mailing Address - Fax:302-995-2121
Practice Address - Street 1:117 LARKSPUR RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-6863
Practice Address - Country:US
Practice Address - Phone:302-738-9963
Practice Address - Fax:302-995-2121
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE112101YA0400X
DE4331101YM0800X
DEPC-0000008101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE2248072OtherCIGNA BEHAVIORAL HEALTH
DE1000036893OtherDE MED. ASSIST. PROGRAM
DE254526OtherCOMPSYCH
DE364878OtherMHN/TRICARE