Basic Information
| Provider Information | |||||||||
| NPI: | 1962621433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANCELLIERI | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | APRN,BC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CANCELLIERI | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
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| OtherCredential: | APRN,BC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15 LAWRENCE ST | ||||||||
| Address2: | |||||||||
| City: | GARDNER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014402337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786320918 | ||||||||
| FaxNumber: | 9787314220 | ||||||||
| Practice Location | |||||||||
| Address1: | 289 GREAT RD | ||||||||
| Address2: | |||||||||
| City: | ACTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017204766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786791225 | ||||||||
| FaxNumber: | 9784864037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 02/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 163573 | MA | N | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163WP0809X | 163573 | MA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 364SP0808X | 163573 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health |
No ID Information.