Mary Dale Cannon, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

2889 Issued in TN

Practice address

2775 Executive Park NW
Suite 1
Cleveland, TN 37312-2763

Phone

(423) 479-9652

NPI assigned

Jan 11, 2010

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other names 1

• Mary D.C. Lauterbach Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1263168000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1509321600000",
    "number": "1477883668",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2775 EXECUTIVE PARK NW",
            "address_2": "SUITE 1",
            "city": "CLEVELAND",
            "state": "TN",
            "postal_code": "373122763",
            "telephone_number": "423-479-1171"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2775 EXECUTIVE PARK NW",
            "address_2": "SUITE 1",
            "city": "CLEVELAND",
            "state": "TN",
            "postal_code": "373122763",
            "telephone_number": "423-479-9652"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CANNON",
        "first_name": "MARY",
        "middle_name": "DALE",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2010-01-11",
        "last_updated": "2017-10-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TB0200X",
            "taxonomy_group": "",
            "desc": "Psychologist, Cognitive & Behavioral",
            "state": "TN",
            "license": "P2889",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "TN",
            "license": "2889",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MARY",
            "last_name": "LAUTERBACH",
            "middle_name": "D.C.",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Camelot Care Centers, Inc
• Cameron Medical LLC
• Rebecca Campbell
• Can DO Kids Pediatric Therapy Services, LLC
• Cancer Risk Associates PLLC
• Philip Andrew Cannon, MS, MFT-I
• Haleigh Cantrell
• Anna Kathleen Carden, FNP-C
• John Stewart Carden, PA-C
• Jessica L Carney, ATC

• Clinical Psychologist in Cleveland, TN
• Providers in Cleveland, TN by specialty
• Clinical Psychologist in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 30, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.