Healthcare Provider Details

I. General information

NPI: 1386308773
Provider Name (Legal Business Name): KELSEY B MONTIEL BT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2021
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E LLANO ESTACADO BLVD
CLOVIS NM
88101-3708
US

IV. Provider business mailing address

201 E LLANO ESTACADO BLVD
CLOVIS NM
88101-3708
US

V. Phone/Fax

Practice location:
  • Phone: 575-763-9517
  • Fax: 575-742-2369
Mailing address:
  • Phone: 575-763-9517
  • Fax: 575-742-2369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: