Provider Demographics
NPI:1053091116
Name:CANNADY, ROMERO
Entity type:Individual
Prefix:
First Name:ROMERO
Middle Name:
Last Name:CANNADY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 NORTHDALE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3006
Mailing Address - Country:US
Mailing Address - Phone:612-408-6638
Mailing Address - Fax:
Practice Address - Street 1:2151 NORTHDALE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3006
Practice Address - Country:US
Practice Address - Phone:612-408-6638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician