Provider Demographics
NPI:1235364522
Name:MONTAVON, PHYLLIS YVONNE (LCSW, LADC)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:YVONNE
Last Name:MONTAVON
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5172 JEWEL CANYON DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-8328
Mailing Address - Country:US
Mailing Address - Phone:702-613-7060
Mailing Address - Fax:
Practice Address - Street 1:4560 S EASTERN AVE STE 13
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6182
Practice Address - Country:US
Practice Address - Phone:702-613-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLADC - 01322-L101YA0400X
NVLCSW 7031-C1041C0700X
NVCSW-INTERN - CI718104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical