Provider Demographics
NPI:1174815419
Name:CANNON, VICTORIA LINDSAY (LCSW)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LINDSAY
Last Name:CANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 E BROADWAY BLVD
Mailing Address - Street 2:B-200
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3534
Mailing Address - Country:US
Mailing Address - Phone:520-795-4977
Mailing Address - Fax:520-795-4981
Practice Address - Street 1:6420 E BROADWAY BLVD
Practice Address - Street 2:B200
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3534
Practice Address - Country:US
Practice Address - Phone:520-818-8945
Practice Address - Fax:520-795-4981
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-126331041C0700X
AZLCSW-141031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical