Provider Demographics
NPI:1134746183
Name:MICK, MONTANA (BSW)
Entity type:Individual
Prefix:MS
First Name:MONTANA
Middle Name:
Last Name:MICK
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:MS
Other - First Name:MONTANA
Other - Middle Name:
Other - Last Name:MICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSW
Mailing Address - Street 1:580 TYRO RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27295-0618
Mailing Address - Country:US
Mailing Address - Phone:336-596-4109
Mailing Address - Fax:
Practice Address - Street 1:1401 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-6300
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician