Provider Demographics
NPI:1508131673
Name:MONTANA, STEPHEN (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MONTANA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5233 WILSON BLVD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-1113
Mailing Address - Country:US
Mailing Address - Phone:703-597-2394
Mailing Address - Fax:
Practice Address - Street 1:5233 WILSON BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-1113
Practice Address - Country:US
Practice Address - Phone:703-597-2394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02207103T00000X
VA0810001582103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist