Provider Demographics
NPI:1306269634
Name:MARTIN, MONTEAL
Entity type:Individual
Prefix:
First Name:MONTEAL
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 N MICHAEL WAY
Mailing Address - Street 2:UNIT C
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4101
Mailing Address - Country:US
Mailing Address - Phone:702-542-5296
Mailing Address - Fax:
Practice Address - Street 1:5546 CAMINO AL NORTE
Practice Address - Street 2:2-333
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-0805
Practice Address - Country:US
Practice Address - Phone:702-910-3230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVPY0416251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV20131272827Medicaid