Provider Demographics
NPI:1740958784
Name:CANTU, ELISA (PSYM, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:CANTU
Suffix:
Gender:F
Credentials:PSYM, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4379
Mailing Address - Country:US
Mailing Address - Phone:505-738-5906
Mailing Address - Fax:505-944-1927
Practice Address - Street 1:6801 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4379
Practice Address - Country:US
Practice Address - Phone:505-605-6572
Practice Address - Fax:505-944-1927
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-21-52508103K00000X
TX4482103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst