| Doctor Name: | MR. TUCKER CROXALL CANNON |
| NPI Number: | 1205969623 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCSW |
| License Number: | 28707 |
| Business Practice Address: | 2046 Allen Ave Rm 100 Altadena, CA - 910013424 |
| Business Phone Number: | 6266609419 |
| Business Fax Number: | |
| Mailing Address: | 204 Main St. Suite 4091, NEWPORT BEACH |
| State: | CA |
| Postal Code: | 926619998 |
| Phone Number: | 9492449982 |
| Fax Number: | |
| NPI Enumeration Date: | 03/14/2007 |
| NPI Last Update Date: | 11/02/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 28707 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |