Provider Demographics
NPI:1740769405
Name:CANCIAMILLE, BROGAN
Entity Type:Individual
Prefix:
First Name:BROGAN
Middle Name:
Last Name:CANCIAMILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SUMMIT ST APT 8
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4257
Mailing Address - Country:US
Mailing Address - Phone:520-661-6200
Mailing Address - Fax:
Practice Address - Street 1:202 N SHOW PLACE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5351
Practice Address - Country:US
Practice Address - Phone:815-332-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010232225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist