Provider Demographics
NPI:1376950162
Name:MONTALDO, MARY E (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:MONTALDO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3000 LASSO WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9611
Mailing Address - Country:US
Mailing Address - Phone:408-833-0406
Mailing Address - Fax:
Practice Address - Street 1:11670 ATWOOD RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-9522
Practice Address - Country:US
Practice Address - Phone:530-887-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29809103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical