Healthcare Provider Details

I. General information

NPI: 1144972779
Provider Name (Legal Business Name): RAUL GULLERMO CANCHOLA PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MARTIN ARMY COMMUNITY HOSPITAL 6600 VAN AALST BLVD
FORT BENNING GA
31905
US

IV. Provider business mailing address

6600 VAN AALST BLVD
FORT BENNING GA
31905-2102
US

V. Phone/Fax

Practice location:
  • Phone: 762-408-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number776
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: