Healthcare Provider Details

I. General information

NPI: 1134355480
Provider Name (Legal Business Name): LUIS DANIEL MONTALVO MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4404 QUEENS BLVD 2ND FL.
SUNNYSIDE NY
11104-2406
US

IV. Provider business mailing address

3316 82ND ST APT. 6B
JACKSON HEIGHTS NY
11372-1444
US

V. Phone/Fax

Practice location:
  • Phone: 718-706-1663
  • Fax:
Mailing address:
  • Phone: 347-451-4401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: