Provider Demographics
NPI:1558446088
Name:CANCILLA, JOAN (MED)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:
Last Name:CANCILLA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 WIGWAM ST
Mailing Address - Street 2:
Mailing Address - City:WELLFLEET
Mailing Address - State:MA
Mailing Address - Zip Code:02667-8825
Mailing Address - Country:US
Mailing Address - Phone:617-791-3139
Mailing Address - Fax:
Practice Address - Street 1:35 A BRITTANY'S WAY
Practice Address - Street 2:# U3
Practice Address - City:EASTHAM
Practice Address - State:MA
Practice Address - Zip Code:02642
Practice Address - Country:US
Practice Address - Phone:617-791-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC 4488101YM0800X
MALMFT 1048106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist