Provider Demographics
NPI:1841981909
Name:MONTOYA, NICOLE R (LSAA, CPSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:MONTOYA
Suffix:
Gender:
Credentials:LSAA, CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MADEIRA DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2963
Mailing Address - Country:US
Mailing Address - Phone:505-262-1538
Mailing Address - Fax:505-242-5302
Practice Address - Street 1:123 MADEIRA DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2963
Practice Address - Country:US
Practice Address - Phone:505-262-1538
Practice Address - Fax:505-242-5302
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
NMCTB-2023-0572101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17034710Medicaid