Provider Demographics
NPI:1518030964
Name:MONTEITH, MARK J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:MONTEITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 BEACON MILL LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8647
Mailing Address - Country:US
Mailing Address - Phone:386-503-3915
Mailing Address - Fax:
Practice Address - Street 1:841 JIMMY ANN DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-4583
Practice Address - Country:US
Practice Address - Phone:386-274-5333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW82831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical