Provider Demographics
NPI:1376950162
Name:MONTALDO, MARY ELISE (MS)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELISE
Last Name:MONTALDO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELISE
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 PALM VALLEY BLVD
Mailing Address - Street 2:#2046
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-1092
Mailing Address - Country:US
Mailing Address - Phone:408-833-0406
Mailing Address - Fax:
Practice Address - Street 1:3282 ADELINE ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2439
Practice Address - Country:US
Practice Address - Phone:510-981-7648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY29809103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program