Provider Demographics
NPI:1043290273
Name:MONTALVO, DIETRA (LCSW)
Entity Type:Individual
Prefix:
First Name:DIETRA
Middle Name:
Last Name:MONTALVO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MCXC DPC MHO
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-7301
Mailing Address - Country:US
Mailing Address - Phone:910-555-5555
Mailing Address - Fax:
Practice Address - Street 1:MCXC DPC MHO
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7301
Practice Address - Country:US
Practice Address - Phone:910-555-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC00045591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical