Provider Demographics
NPI:1710194238
Name:MONTAGUE, REBECCA C (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:C
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4507 WHITNEY HILL CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-4392
Mailing Address - Country:US
Mailing Address - Phone:502-261-0813
Mailing Address - Fax:
Practice Address - Street 1:4507 WHITNEY HILL CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-4392
Practice Address - Country:US
Practice Address - Phone:502-261-0813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0942901Medicare ID - Type Unspecified