Provider Demographics
NPI:1083251987
Name:MONTENEGRO, IVAN FEDERICO (BACHELORS OF ARTS)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:FEDERICO
Last Name:MONTENEGRO
Suffix:
Gender:M
Credentials:BACHELORS OF ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 S PROSPERO DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3250
Mailing Address - Country:US
Mailing Address - Phone:213-548-0555
Mailing Address - Fax:
Practice Address - Street 1:578 S PROSPERO DR
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3250
Practice Address - Country:US
Practice Address - Phone:213-548-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
CA1-21-53131103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-0617904OtherPRIVATE INSURANCE