Provider Demographics
NPI:1770017055
Name:MONTOYA, MICHAEL (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MONTOYA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2560
Mailing Address - Country:US
Mailing Address - Phone:575-512-9082
Mailing Address - Fax:
Practice Address - Street 1:724 PARK LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435
Practice Address - Country:US
Practice Address - Phone:575-472-5383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-09888104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker