Healthcare Provider Details

I. General information

NPI: 1780023556
Provider Name (Legal Business Name): CYNTHIA MARGARET KANTOS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CYNTHIA MARGARET MOSS LSW

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 12/31/2020
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 34TH ST NW
BEMIDJI MN
56601-5112
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-5000
  • Fax: 218-333-5360
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number26648
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4845
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26648
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: