Healthcare Provider Details

I. General information

NPI: 1043171846
Provider Name (Legal Business Name): LACRESHA CHARISSE MONTOYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2025
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E OSBORN RD
PHOENIX AZ
85012-2327
US

IV. Provider business mailing address

205 E OSBORN RD
PHOENIX AZ
85012-2327
US

V. Phone/Fax

Practice location:
  • Phone: 602-283-5832
  • Fax:
Mailing address:
  • Phone: 602-283-5832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberCHW0000000649
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCHW0000000649
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: