Provider Demographics
NPI:1821536657
Name:CANTON, AMY GRACE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:GRACE
Last Name:CANTON
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 1:411 ALAMEDA DEL PRADO
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6302
Mailing Address - Country:US
Mailing Address - Phone:415-302-2835
Mailing Address - Fax:
Practice Address - Street 1:411 ALAMEDA DEL PRADO
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6302
Practice Address - Country:US
Practice Address - Phone:415-302-2835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAI88065101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health