Provider Demographics
NPI:1700546488
Name:CANCILLA, CHARLES E (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:CANCILLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 DUNCANS SHORE DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-6222
Mailing Address - Country:US
Mailing Address - Phone:404-218-0180
Mailing Address - Fax:
Practice Address - Street 1:897 EVA KENNEDY RD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1911
Practice Address - Country:US
Practice Address - Phone:404-400-2547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4473103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist