Provider Demographics
NPI:1437349800
Name:MONTAGNE, BERNADETTE (LAT)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:MONTAGNE
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 W BRUNDAGE ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4217
Mailing Address - Country:US
Mailing Address - Phone:307-674-1668
Mailing Address - Fax:307-674-1667
Practice Address - Street 1:151 W BRUNDAGE ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4217
Practice Address - Country:US
Practice Address - Phone:307-674-1668
Practice Address - Fax:307-674-1667
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT-210101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYMON314194OtherBLUE CROSS BLUE SHIELD