Provider Demographics
NPI:1164800553
Name:MARK B CANTALES, LICENSED CLINICAL SOCIAL WORKER,PC
Entity Type:Organization
Organization Name:MARK B CANTALES, LICENSED CLINICAL SOCIAL WORKER,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTALES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSWR
Authorized Official - Phone:607-372-1020
Mailing Address - Street 1:217 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5244
Mailing Address - Country:US
Mailing Address - Phone:607-372-1020
Mailing Address - Fax:607-239-5328
Practice Address - Street 1:217 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5244
Practice Address - Country:US
Practice Address - Phone:607-372-1020
Practice Address - Fax:607-239-5328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069788R1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty