MEDICARE: DIETRA MONTALVO LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	1041C0700X	Clinical Social Worker	C0004559	NC

General Provider Information

NPI Number	:	1043290273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIETRA MONTALVO LCSW

Provider Business Mailing Address
First Line	:	2817 ROCK MERRITT AVENUE
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-7301
Country	:	US
Telephone Number	:	910-907-8922
Fax Number	:	910-907-8707

Provider Business Practice Location Address
First Line	:	2817 ROCK MERRITT AVENUE
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-7301
Country	:	US
Telephone Number	:	910-907-8922
Fax Number	:	910-907-6069

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	07/22/2025

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