Provider Demographics
NPI:1588403703
Name:CANNIS, DIANA (LAC)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CANNIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 MAIN ST APT 305
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-7482
Mailing Address - Country:US
Mailing Address - Phone:609-772-0882
Mailing Address - Fax:
Practice Address - Street 1:74 BRICK BLVD BLDG 4
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-7984
Practice Address - Country:US
Practice Address - Phone:732-992-8171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00775000101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor