Provider Demographics
NPI:1417391780
Name:MONTANEZ, VICTORIA J (BS, MS)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:J
Last Name:MONTANEZ
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1642
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-1642
Mailing Address - Country:US
Mailing Address - Phone:307-751-6449
Mailing Address - Fax:
Practice Address - Street 1:152 N DURBIN ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1931
Practice Address - Country:US
Practice Address - Phone:307-265-2575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY251B00000X251B00000X
WYPPC949101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1417391780Medicaid