Healthcare Provider Details

I. General information

NPI: 1265833859
Provider Name (Legal Business Name): KELLY CANTISANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 BEAR TAVERN RD MEDOP BEHAVIORAL HEALTH ASSOCIATES OF NJ PC
EWING NJ
08628-1020
US

IV. Provider business mailing address

830 BEAR TAVERN RD MEDOP BEHAVIORAL HEALTH ASSOCIATES OF NJ PC
EWING NJ
08628-1020
US

V. Phone/Fax

Practice location:
  • Phone: 973-800-2655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number26NJ00005800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: