Provider Demographics
NPI:1376695023
Name:MONTVILLE, MARILYN FENTON
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:FENTON
Last Name:MONTVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:
Other - Last Name:FENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1514 SHEPARD PL
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4220
Mailing Address - Country:US
Mailing Address - Phone:307-587-9596
Mailing Address - Fax:
Practice Address - Street 1:721 SHERIDAN AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3423
Practice Address - Country:US
Practice Address - Phone:307-527-5312
Practice Address - Fax:307-578-2212
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY237101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY11661674OtherCAQH UNIVERSAL CREDENTIAL