Active NPI
Charles E Cancilla, PH.D.
- Psychologist
- Suwanee, GA
National Provider Identifier
1700546488
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 4473
- Practice address
- 897 Eva Kennedy Rd
Suwanee, GA 30024-1911 - Phone
- (404) 400-2547
- NPI assigned
- Dec 22, 2021
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 4473 | GA | Primary |
Addresses
Primary practice location
897 Eva Kennedy Rd
Suwanee, GA 30024-1911
Mailing address
2345 Duncans Shore Dr
Buford, GA 30519-6222
Phone (404) 218-0180
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4473 | GA | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1640131200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1640131200000",
"number": "1700546488",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2345 DUNCANS SHORE DR",
"city": "BUFORD",
"state": "GA",
"postal_code": "305196222",
"telephone_number": "404-218-0180"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "897 EVA KENNEDY RD",
"city": "SUWANEE",
"state": "GA",
"postal_code": "300241911",
"telephone_number": "404-400-2547"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CANCILLA",
"first_name": "CHARLES",
"middle_name": "E",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2021-12-22",
"last_updated": "2021-12-22",
"certification_date": "2021-12-22",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "GA",
"license": "4473",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Suwanee, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.