Healthcare Provider Details

I. General information

NPI: 1144134834
Provider Name (Legal Business Name): MYLES MONTAQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7752 N CANTON CENTER RD
CANTON MI
48187-1328
US

IV. Provider business mailing address

1960 WOODBURY DR
ANN ARBOR MI
48104-4679
US

V. Phone/Fax

Practice location:
  • Phone: 815-474-6305
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: