Provider Demographics
NPI:1366483125
Name:MONTAQUILLA, SUSAN (LMHC, LCDP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MONTAQUILLA
Suffix:
Gender:F
Credentials:LMHC, LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 HOWARD AVE BLDG 56
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-3001
Practice Address - Country:US
Practice Address - Phone:401-462-1021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00329101YM0800X
RILCDP00239101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI414072OtherBLUE CHIP
RI32427-4OtherBLUE CROSS
RI62-42464OtherUBH
RISM55220Medicaid
RI1104847946OtherTHE PROVIDENCE CENTER NPI