Healthcare Provider Details

I. General information

NPI: 1578496840
Provider Name (Legal Business Name): MELISIA LEE MONTANO CPSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 A S. MCCURDY
ESPANOLA NM
87532
US

IV. Provider business mailing address

PO BOX 1360
PENA BLANCA NM
87041-1360
US

V. Phone/Fax

Practice location:
  • Phone: 505-640-3510
  • Fax:
Mailing address:
  • Phone: 505-640-3510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number584
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: