Provider Demographics
NPI:1518524743
Name:MONTAGUE, THERESA NINA (LPC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:NINA
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 DALLAS HWY SW STE 202-1285
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2567
Mailing Address - Country:US
Mailing Address - Phone:470-370-0242
Mailing Address - Fax:
Practice Address - Street 1:715 PEACHTREE ST NE STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2179
Practice Address - Country:US
Practice Address - Phone:678-744-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010709101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional