Provider Demographics
NPI:1720696057
Name:MCCANNA, COLMAN CARROLL
Entity type:Individual
Prefix:MR
First Name:COLMAN
Middle Name:CARROLL
Last Name:MCCANNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 MONTANO PLAZA DR NW APT 2427
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5786
Mailing Address - Country:US
Mailing Address - Phone:260-437-6962
Mailing Address - Fax:
Practice Address - Street 1:3876 HAWKINS ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4539
Practice Address - Country:US
Practice Address - Phone:505-508-0865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician