Healthcare Provider Details

I. General information

NPI: 1821170630
Provider Name (Legal Business Name): JAY ROBERT CANTOR CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 NAAMANS RD
CLAYMONT DE
19703-2308
US

IV. Provider business mailing address

503 BRIER AVE
WILMINGTON DE
19805-1963
US

V. Phone/Fax

Practice location:
  • Phone: 833-886-2277
  • Fax:
Mailing address:
  • Phone: 215-518-9197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW013457
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ1-0000471
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: