Healthcare Provider Details

I. General information

NPI: 1770225773
Provider Name (Legal Business Name): JOSEPH ANTHONY MONTELLANO LCDC, LPC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BJ MONTELLANO

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 CULEBRA RD
SAN ANTONIO TX
78228-5914
US

IV. Provider business mailing address

6238 PELICAN CORAL
SAN ANTONIO TX
78244-1635
US

V. Phone/Fax

Practice location:
  • Phone: 210-314-6473
  • Fax: 210-314-8676
Mailing address:
  • Phone: 210-309-0739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15924
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: