1811210768 NPI number — MS. KATRELLIA MONTAGUE LCSW, MPH

Table of content: MS. KATRELLIA MONTAGUE LCSW, MPH (NPI 1811210768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811210768 NPI number — MS. KATRELLIA MONTAGUE LCSW, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTAGUE
Provider First Name:
KATRELLIA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, MPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811210768
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4205 BAY RUM LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27610-6183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-771-2010
Provider Business Mailing Address Fax Number:
919-771-2050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 W 145TH ST
Provider Second Line Business Practice Location Address:
PMB 7
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10031-5403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-744-5496
Provider Business Practice Location Address Fax Number:
919-771-2050
Provider Enumeration Date:
03/08/2010

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: 1041C0700X , with the licence number:  R012889 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com