Healthcare Provider Details

I. General information

NPI: 1457683641
Provider Name (Legal Business Name): DANIELLE LANE MONTANA L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 SAN NICOLAS WAY
SAINT AUGUSTINE FL
32080-7712
US

IV. Provider business mailing address

396 SAN NICOLAS WAY
SAINT AUGUSTINE FL
32080-7712
US

V. Phone/Fax

Practice location:
  • Phone: 239-248-4060
  • Fax:
Mailing address:
  • Phone: 239-248-4060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8969
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13399
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06329200
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number904007304
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: