Provider Demographics
NPI:1023140522
Name:MCCANN, GENEVA SUE (PSYD)
Entity type:Individual
Prefix:DR
First Name:GENEVA
Middle Name:SUE
Last Name:MCCANN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4500 WILLIAMS DR
Mailing Address - Street 2:STE 212182
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633-1332
Mailing Address - Country:US
Mailing Address - Phone:808-937-8783
Mailing Address - Fax:808-443-0185
Practice Address - Street 1:102 W MORROW ST
Practice Address - Street 2:SUITE 202
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-4307
Practice Address - Country:US
Practice Address - Phone:808-937-8783
Practice Address - Fax:808-443-0185
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX36607103TC0700X
HIPSY652103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIP02174Medicare UPIN