Provider Demographics
NPI:1629162771
Name:MONTOUR, ELIZABETH A (MSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:MONTOUR
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 E GREEN BAY ST
Mailing Address - Street 2:STE 191
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-3879
Mailing Address - Country:US
Mailing Address - Phone:715-526-5466
Mailing Address - Fax:715-526-5545
Practice Address - Street 1:1415 E GREEN BAY ST
Practice Address - Street 2:STE 191
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3879
Practice Address - Country:US
Practice Address - Phone:715-526-5466
Practice Address - Fax:715-526-5545
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7274123101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40925100Medicaid
WI0006Medicare ID - Type Unspecified