1295984441 NPI number — MRS. GRACE WILLSON CANTOR M.A.

Table of content: MRS. GRACE WILLSON CANTOR M.A. (NPI 1295984441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295984441 NPI number — MRS. GRACE WILLSON CANTOR M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANTOR
Provider First Name:
GRACE
Provider Middle Name:
WILLSON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLSON
Provider Other First Name:
GRACE
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1295984441
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
443 NE KNOTT ST
Provider Second Line Business Mailing Address:
KNOTT STREET HEALTH CENTER
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97212-3108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-894-0547
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
443 NE KNOTT ST
Provider Second Line Business Practice Location Address:
KNOTT STREET HEALTH CENTER
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97212-3108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-894-0547
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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