Provider Demographics
NPI:1902368004
Name:MONTEMBAULT, STEPHEN R (LADC1)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:R
Last Name:MONTEMBAULT
Suffix:
Gender:M
Credentials:LADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 KILBURN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-7321
Mailing Address - Country:US
Mailing Address - Phone:774-628-1001
Mailing Address - Fax:508-997-0765
Practice Address - Street 1:33 S 6TH ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-5907
Practice Address - Country:US
Practice Address - Phone:774-202-4820
Practice Address - Fax:774-202-0825
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1584101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)