Provider Demographics
NPI:1295961019
Name:CANNON, FRED REEVES III (MA, LPC, BCPCC)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:REEVES
Last Name:CANNON
Suffix:III
Gender:M
Credentials:MA, LPC, BCPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 3RD LOOP RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-3709
Mailing Address - Country:US
Mailing Address - Phone:843-662-2021
Mailing Address - Fax:843-662-2021
Practice Address - Street 1:1140 3RD LOOP RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-3709
Practice Address - Country:US
Practice Address - Phone:843-662-2021
Practice Address - Fax:843-662-2021
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5016101YP1600X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral