Provider Demographics
NPI:1194958934
Name:CANCILLA, WENDI-JO BIANCA (LMHC)
Entity type:Individual
Prefix:MS
First Name:WENDI-JO
Middle Name:BIANCA
Last Name:CANCILLA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19249
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-9249
Mailing Address - Country:US
Mailing Address - Phone:904-743-1883
Mailing Address - Fax:904-743-5109
Practice Address - Street 1:4080 WOODCOCK DR
Practice Address - Street 2:MIDTOWN CENTRE, BUILDING 2400, SUITE 105
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2722
Practice Address - Country:US
Practice Address - Phone:904-396-1770
Practice Address - Fax:904-396-1897
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8430101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767278100Medicaid