Provider Demographics
NPI:1437212156
Name:MONTANYE, LARUE R (DED)
Entity Type:Individual
Prefix:DR
First Name:LARUE
Middle Name:R
Last Name:MONTANYE
Suffix:
Gender:M
Credentials:DED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 BROAD ST
Mailing Address - Street 2:P.O. BOX 125
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-2221
Mailing Address - Country:US
Mailing Address - Phone:570-368-2624
Mailing Address - Fax:570-368-2212
Practice Address - Street 1:355 BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-2221
Practice Address - Country:US
Practice Address - Phone:570-368-2624
Practice Address - Fax:570-368-2212
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002406L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA078268OtherFPH
PA376851OtherBLUE CROSS
PA376851OtherBLUE CROSS