Healthcare Provider Details

I. General information

NPI: 1316245806
Provider Name (Legal Business Name): MISS LEAH THERESA MONTOYA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2011
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 ASHLEY LN
CORRALES NM
87048-8917
US

IV. Provider business mailing address

409 ASHLEY LN
CORRALES NM
87048-8917
US

V. Phone/Fax

Practice location:
  • Phone: 505-917-1762
  • Fax:
Mailing address:
  • Phone: 505-917-1762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-25540
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: