Provider Demographics
NPI:1932807591
Name:MONTEITH, MYA D (LMT)
Entity Type:Individual
Prefix:
First Name:MYA
Middle Name:D
Last Name:MONTEITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 105TH ST
Mailing Address - Street 2:
Mailing Address - City:LUCK
Mailing Address - State:WI
Mailing Address - Zip Code:54853-5141
Mailing Address - Country:US
Mailing Address - Phone:171-597-7234
Mailing Address - Fax:
Practice Address - Street 1:610 WEST AVE STE A-2
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1386
Practice Address - Country:US
Practice Address - Phone:715-296-7467
Practice Address - Fax:888-262-0191
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171400000X, 374J00000X
174N00000X
WI11559-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171400000XOther Service ProvidersHealth & Wellness Coach
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula