Provider Demographics
NPI:1992066716
Name:CANNON, BARBARA O'MALLEY (PHD, BCBA)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:O'MALLEY
Last Name:CANNON
Suffix:
Gender:F
Credentials:PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1980 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-3804
Mailing Address - Country:US
Mailing Address - Phone:978-371-0093
Mailing Address - Fax:
Practice Address - Street 1:461 RIVER RD
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-4213
Practice Address - Country:US
Practice Address - Phone:781-223-1198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-04-1955103K00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist