=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932928231
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL NICOLE MONTEMAYOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2024
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 E 144TH ST
-----------------------------------------------------
City | EAST CHICAGO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46312-3046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-391-4100
-----------------------------------------------------
Fax | 219-391-4126
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5030 WALSH AVE
-----------------------------------------------------
City | EAST CHICAGO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46312-3654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-801-1190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 10138003
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------