Provider Demographics
NPI:1205651429
Name:MONTALTO, DIANA JEANNE
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:JEANNE
Last Name:MONTALTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 STAPLETON RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3375
Mailing Address - Country:US
Mailing Address - Phone:773-480-1971
Mailing Address - Fax:
Practice Address - Street 1:21 S WHITE ST STE 3
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-4007
Practice Address - Country:US
Practice Address - Phone:773-480-1971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017765101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health