Provider Demographics
NPI:1689027203
Name:DENISON/CANNON, CRYSTAL (SUDRC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:DENISON/CANNON
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EASTON DR STE 151
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-9406
Mailing Address - Country:US
Mailing Address - Phone:661-634-9737
Mailing Address - Fax:661-864-0198
Practice Address - Street 1:1010 1/2 S UNION AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93307-3642
Practice Address - Country:US
Practice Address - Phone:661-321-0234
Practice Address - Fax:661-864-0198
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9553101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)