Provider Demographics
NPI:1265833859
Name:CANTISANO, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CANTISANO
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 1:830 BEAR TAVERN RD
Mailing Address - Street 2:MEDOP BEHAVIORAL HEALTH ASSOCIATES OF NJ PC
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08628-1020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 BEAR TAVERN RD
Practice Address - Street 2:MEDOP BEHAVIORAL HEALTH ASSOCIATES OF NJ PC
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628-1020
Practice Address - Country:US
Practice Address - Phone:973-800-2655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00005800364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult