Provider Demographics
NPI:1235685462
Name:CANTORAN, MARY
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:CANTORAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 INLAND EMPIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4898
Mailing Address - Country:US
Mailing Address - Phone:909-458-1350
Mailing Address - Fax:
Practice Address - Street 1:2940 INLAND EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4898
Practice Address - Country:US
Practice Address - Phone:909-458-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251J00000X, 273R00000X, 276400000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No251J00000XAgenciesNursing Care
No273R00000XHospital UnitsPsychiatric Unit
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30275OtherSOMON#