Provider Demographics
NPI:1952062168
Name:CANCILLA, LUKE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:CANCILLA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9447B LORTON MARKET ST # 250
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1963
Mailing Address - Country:US
Mailing Address - Phone:703-372-5712
Mailing Address - Fax:888-965-8857
Practice Address - Street 1:9447B LORTON MARKET ST # 250
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-1963
Practice Address - Country:US
Practice Address - Phone:703-372-5712
Practice Address - Fax:888-965-8857
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214865225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist