Provider Demographics
NPI:1053718759
Name:KANTACK, GEOFFREY (LMSW)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
Last Name:KANTACK
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5718 KENMOOR RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1018
Mailing Address - Country:US
Mailing Address - Phone:914-522-0531
Mailing Address - Fax:
Practice Address - Street 1:2075 W BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3407
Practice Address - Country:US
Practice Address - Phone:248-646-6659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010967241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical