Provider Demographics
NPI:1699132266
Name:MONTICELLO, CHRISTOPHER
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:MONTICELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 EMPIRE STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9751
Mailing Address - Country:US
Mailing Address - Phone:518-396-3520
Mailing Address - Fax:
Practice Address - Street 1:10 EMPIRE STATE BLVD
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9751
Practice Address - Country:US
Practice Address - Phone:518-396-3520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068696104100000X
NY0867361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid