Healthcare Provider Details

I. General information

NPI: 1275363905
Provider Name (Legal Business Name): JUAN CARLOS MONTANEZ-LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 LIBERTY ST
SPRINGFIELD MA
01104-3736
US

IV. Provider business mailing address

417 LIBERTY ST
SPRINGFIELD MA
01104-3736
US

V. Phone/Fax

Practice location:
  • Phone: 413-301-9355
  • Fax: 413-733-7841
Mailing address:
  • Phone: 413-301-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: