MEDICARE: RAYMOND JOHN CANCEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1760526347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYMOND JOHN CANCEL

Provider Business Mailing Address
First Line	:	4025 FLORIDA ST
Second Line	:	UNIT 10
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-6000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2221 CAMINO DEL RIO S
Second Line	:	STE. 105
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3608
Country	:	US
Telephone Number	:	619-220-0421
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	07/08/2007

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Directions to “ RAYMOND JOHN CANCEL ” Practice Location

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