Healthcare Provider Details

I. General information

NPI: 1306269634
Provider Name (Legal Business Name): MONTEAL MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5546 CAMINO AL NORTE 2-333
NORTH LAS VEGAS NV
89031-0805
US

IV. Provider business mailing address

3109 N MICHAEL WAY UNIT C
LAS VEGAS NV
89108-4101
US

V. Phone/Fax

Practice location:
  • Phone: 702-910-3230
  • Fax:
Mailing address:
  • Phone: 702-542-5296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberNVPY0416
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: