Provider Demographics
NPI:1891358412
Name:MONTENEGRO, MARIELA NELLY (LMT)
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:NELLY
Last Name:MONTENEGRO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 SOUTHBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6264
Mailing Address - Country:US
Mailing Address - Phone:210-548-9128
Mailing Address - Fax:
Practice Address - Street 1:114 SOUTHBRIDGE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6264
Practice Address - Country:US
Practice Address - Phone:210-548-9128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT120921225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist