Healthcare Provider Details

I. General information

NPI: 1407746308
Provider Name (Legal Business Name): LISETTE M MONTALVO MA, LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2025
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11785 BELTSVILLE DR STE 120
CALVERTON MD
20705-3121
US

IV. Provider business mailing address

11785 BELTSVILLE DR STE 120
CALVERTON MD
20705-3121
US

V. Phone/Fax

Practice location:
  • Phone: 240-389-1487
  • Fax:
Mailing address:
  • Phone: 240-389-1487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLGP15916
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLGP15916
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP15916
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP15916
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: