Provider Demographics
NPI:1285728287
Name:MONTELLO, CORY (LCSW)
Entity type:Individual
Prefix:MS
First Name:CORY
Middle Name:
Last Name:MONTELLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MONTAUK HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:BLUE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11715
Mailing Address - Country:US
Mailing Address - Phone:631-462-0597
Mailing Address - Fax:631-363-0027
Practice Address - Street 1:20 MONTAUK HIGHWAY
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715
Practice Address - Country:US
Practice Address - Phone:631-462-0597
Practice Address - Fax:631-363-0027
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR0247201103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN97331Medicare ID - Type Unspecified