| Doctor Name: | CALLEEN ANN CANNON |
| NPI Number: | 1316144819 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | L.P.C., N.C.C. |
| License Number: | LPC 3723 |
| Business Practice Address: | 4460 Kings Way Ste 2 Chubbuck, ID - 832021900 |
| Business Phone Number: | 2082371711 |
| Business Fax Number: | |
| Mailing Address: | 2450 E Terry St Apt 4, POCATELLO |
| State: | ID |
| Postal Code: | 832012743 |
| Phone Number: | 2082411689 |
| Fax Number: | |
| NPI Enumeration Date: | 06/28/2007 |
| NPI Last Update Date: | 07/08/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | LPC 3723 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |