Provider Demographics
NPI:1598162307
Name:MONTANEZ, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MONTANEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SAINT JACOB ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-4951
Mailing Address - Country:US
Mailing Address - Phone:585-713-4363
Mailing Address - Fax:
Practice Address - Street 1:85 SAINT JACOB ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-4951
Practice Address - Country:US
Practice Address - Phone:585-342-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0649181041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool