Provider Demographics
NPI:1164998233
Name:MONTAGUE, MARTIN EDWARD
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:EDWARD
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SE WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3058
Mailing Address - Country:US
Mailing Address - Phone:360-748-4776
Mailing Address - Fax:
Practice Address - Street 1:500 SE WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3058
Practice Address - Country:US
Practice Address - Phone:360-748-4776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP6034314101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)