Provider Demographics
NPI:1285418947
Name:MONTIQUE, CHESMORE SIMON (PHD)
Entity type:Individual
Prefix:DR
First Name:CHESMORE
Middle Name:SIMON
Last Name:MONTIQUE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6194 SAINT CHRISTOPHERS CT
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-7964
Practice Address - Country:US
Practice Address - Phone:732-910-3121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling