Basic Information
| Provider Information | |||||||||
| NPI: | 1326433962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 E 51ST ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908056598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102216336 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 HUGHES WAY | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908101876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102216336 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2015 | ||||||||
| LastUpdateDate: | 03/31/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF78535 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.