Provider Demographics
NPI:1316374572
Name:MONTAGUE, BONNIE L (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:L
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 FAIRWAY DR APT 324
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-6118
Mailing Address - Country:US
Mailing Address - Phone:781-413-1728
Mailing Address - Fax:
Practice Address - Street 1:4 FAIRWAY DR APT 324
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-6118
Practice Address - Country:US
Practice Address - Phone:781-413-1728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-13-13623103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst