Provider Demographics
NPI:1700328580
Name:MONTALVO, GRACIELA (CASAC)
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:
Last Name:MONTALVO
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-3256
Mailing Address - Country:US
Mailing Address - Phone:631-921-3941
Mailing Address - Fax:
Practice Address - Street 1:1235 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-2917
Practice Address - Country:US
Practice Address - Phone:631-647-2154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)