Basic Information
| Provider Information | |||||||||
| NPI: | 1750957817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANCEL | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175F CENTRE ST APT 610 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021698612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735809249 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021847599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178471950 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2021 | ||||||||
| LastUpdateDate: | 05/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.