Healthcare Provider Details

I. General information

NPI: 1548460439
Provider Name (Legal Business Name): SUSAN MONTAGUE LCP, LCAC, LMLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN THOMAS

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 E IRON AVE STE C
SALINA KS
67401-2697
US

IV. Provider business mailing address

509 E ELM ST
SALINA KS
67401-2353
US

V. Phone/Fax

Practice location:
  • Phone: 800-423-1342
  • Fax: 785-628-3113
Mailing address:
  • Phone: 800-423-1342
  • Fax: 785-628-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number050
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2811
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number011
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: