Provider Demographics
NPI:1639653413
Name:MONTAGUE, CHAD WARREN (LLBSW)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:WARREN
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 PASADENA DR
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-1130
Mailing Address - Country:US
Mailing Address - Phone:989-251-6662
Mailing Address - Fax:
Practice Address - Street 1:1420 WEST UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504
Practice Address - Country:US
Practice Address - Phone:810-238-0475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802090120104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802090120OtherLLBSW