Provider Demographics
NPI:1922162643
Name:CANTALES, MARK BLAINE (LCSWR)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BLAINE
Last Name:CANTALES
Suffix:
Gender:M
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5244
Mailing Address - Country:US
Mailing Address - Phone:607-372-1020
Mailing Address - Fax:607-239-5328
Practice Address - Street 1:217 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5244
Practice Address - Country:US
Practice Address - Phone:607-372-1020
Practice Address - Fax:607-239-5328
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069788-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA7926Medicare ID - Type Unspecified