Provider Demographics
NPI:1972974442
Name:MONTANA, MICHELLE (LLMSW, CADC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MONTANA
Suffix:
Gender:F
Credentials:LLMSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9851 VFW RD
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-9791
Mailing Address - Country:US
Mailing Address - Phone:517-213-8939
Mailing Address - Fax:
Practice Address - Street 1:4287 FIVE OAKS DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4214
Practice Address - Country:US
Practice Address - Phone:517-882-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10209101YA0400X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1518357649Medicaid