Provider Demographics
NPI:1245476753
Name:MONTAGUE, AMY DIANE (PHD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:DIANE
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:260 NEWPORT CENTER DR
Mailing Address - Street 2:STE 209
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7520
Mailing Address - Country:US
Mailing Address - Phone:310-497-7047
Mailing Address - Fax:
Practice Address - Street 1:74710 HIGHWAY 111 STE 102
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3820
Practice Address - Country:US
Practice Address - Phone:310-497-7047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CAPSY 16740103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1770668097OtherNPI TYPE II
CAQ09780Medicare UPIN
CACP 16740Medicare PIN