Provider Demographics
NPI:1821459751
Name:MONTAUBAN, BRITTANY
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:MONTAUBAN
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 1:865 BROADWAY AVE
Mailing Address - Street 2:APT. 107B
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4953
Mailing Address - Country:US
Mailing Address - Phone:631-219-7555
Mailing Address - Fax:
Practice Address - Street 1:7000 AUSTIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1022
Practice Address - Country:US
Practice Address - Phone:718-762-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-20
Last Update Date:2016-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3580519174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist