Healthcare Provider Details

I. General information

NPI: 1801539077
Provider Name (Legal Business Name): CHARLENE MONTOYA PSYD, LED, ASDCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1762 MAIN STREET
SAN ANTONIO NM
87832
US

IV. Provider business mailing address

PO BOX 463
SAN ANTONIO NM
87832-0463
US

V. Phone/Fax

Practice location:
  • Phone: 575-418-0675
  • Fax:
Mailing address:
  • Phone: 575-418-0675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number285442
License Number StateNM
# 5
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number285442
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: