Healthcare Provider Details

I. General information

NPI: 1386990810
Provider Name (Legal Business Name): CHRISTAL NICOLE MONTAGUE MSW, LMHC, CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 MADISON AVE
NEW YORK NY
10035-1217
US

IV. Provider business mailing address

2006 MADISON AVE
NEW YORK NY
10035-1217
US

V. Phone/Fax

Practice location:
  • Phone: 212-979-8800
  • Fax:
Mailing address:
  • Phone: 212-979-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number002134-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: