Provider Demographics
NPI:1144738691
Name:KANTOR, EVAN ROSS
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:ROSS
Last Name:KANTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BEAUMONT LN
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2736
Mailing Address - Country:US
Mailing Address - Phone:631-707-5462
Mailing Address - Fax:
Practice Address - Street 1:21 BEAUMONT LN
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2736
Practice Address - Country:US
Practice Address - Phone:631-707-5462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY877004039101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1293728403OtherUNITEDHEALTHCARE-OXFORD