Provider Demographics
NPI:1982151460
Name:CANNON, LAVERNE BERNETTE (LCASA)
Entity type:Individual
Prefix:
First Name:LAVERNE
Middle Name:BERNETTE
Last Name:CANNON
Suffix:
Gender:F
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2152 M4 FLAGSTONE COURT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834
Mailing Address - Country:US
Mailing Address - Phone:252-902-7184
Mailing Address - Fax:
Practice Address - Street 1:2152 FLAGSTONE CT APT M4
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8794
Practice Address - Country:US
Practice Address - Phone:252-902-7184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3503A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)