Provider Demographics
NPI:1336640341
Name:KANTOR, ELISE (MPT)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:KANTOR
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31145 KINGSWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1624
Mailing Address - Country:US
Mailing Address - Phone:248-921-5250
Mailing Address - Fax:
Practice Address - Street 1:40245 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2119
Practice Address - Country:US
Practice Address - Phone:248-473-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-25
Last Update Date:2018-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist