Provider Demographics
NPI:1801539077
Name:MONTOYA, CHARLENE (PSYD, LED, ASDCS)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:MONTOYA
Suffix:
Gender:F
Credentials:PSYD, LED, ASDCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 463
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:NM
Mailing Address - Zip Code:87832-0463
Mailing Address - Country:US
Mailing Address - Phone:575-418-0675
Mailing Address - Fax:
Practice Address - Street 1:1762 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:NM
Practice Address - Zip Code:87832
Practice Address - Country:US
Practice Address - Phone:575-418-0675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171400000X, 171M00000X
NM285442251S00000X, 2080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty