Provider Demographics
NPI:1578796371
Name:CANTILLON, CHERYL A (OTR)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:A
Last Name:CANTILLON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-1836
Mailing Address - Country:US
Mailing Address - Phone:860-287-7107
Mailing Address - Fax:
Practice Address - Street 1:46 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-1836
Practice Address - Country:US
Practice Address - Phone:860-287-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001883320700000X
MA8902323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility