Provider Demographics
NPI:1750043741
Name:KANTOR, KELLEY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:KANTOR
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 1:60 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-1552
Mailing Address - Country:US
Mailing Address - Phone:419-631-1675
Mailing Address - Fax:
Practice Address - Street 1:1451 LUCAS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-8682
Practice Address - Country:US
Practice Address - Phone:419-589-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator