Provider Demographics
NPI:1295984441
Name:CANTOR, GRACE WILLSON (MA)
Entity type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:WILLSON
Last Name:CANTOR
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:GRACE
Other - Middle Name:ELIZABETH
Other - Last Name:WILLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:443 NE KNOTT ST
Mailing Address - Street 2:KNOTT STREET HEALTH CENTER
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3108
Mailing Address - Country:US
Mailing Address - Phone:503-894-0547
Mailing Address - Fax:
Practice Address - Street 1:443 NE KNOTT ST
Practice Address - Street 2:KNOTT STREET HEALTH CENTER
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3108
Practice Address - Country:US
Practice Address - Phone:503-894-0547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health