Provider Demographics
NPI:1962931279
Name:CANTU, ELYSSE GLORIA
Entity type:Individual
Prefix:
First Name:ELYSSE
Middle Name:GLORIA
Last Name:CANTU
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 1:161 E RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-4921
Mailing Address - Country:US
Mailing Address - Phone:626-622-2438
Mailing Address - Fax:
Practice Address - Street 1:8135 PAINTER AVE STE 201
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-3166
Practice Address - Country:US
Practice Address - Phone:562-698-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician