Provider Demographics
NPI:1295864528
Name:CANCELL, DAVID (MA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:CANCELL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 GLEN AVE
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1620
Mailing Address - Country:US
Mailing Address - Phone:973-379-4370
Mailing Address - Fax:
Practice Address - Street 1:236 GLEN AVE
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1620
Practice Address - Country:US
Practice Address - Phone:973-379-4370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ686103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJCA176 890Medicare PIN
NJB92977Medicare UPIN