Provider Demographics
NPI:1891904488
Name:MONTIJO, ANNE MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANNE
Middle Name:MARIE
Last Name:MONTIJO
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 1:3 HALE LN
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-2903
Mailing Address - Country:US
Mailing Address - Phone:631-428-6475
Mailing Address - Fax:
Practice Address - Street 1:1050 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1214
Practice Address - Country:US
Practice Address - Phone:631-428-6475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045239-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR045239-1OtherLICENSE NUMBER
NYR045239-1OtherLICENSE NUMBER