Provider Demographics
NPI:1992078828
Name:MONTAGUE, KEVIN J (MS, LPC, LSAC, LSW)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:J
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:MS, LPC, LSAC, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 POLK COUNTY PLZ
Mailing Address - Street 2:STE 50
Mailing Address - City:BALSAM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54810-9071
Mailing Address - Country:US
Mailing Address - Phone:715-485-8862
Mailing Address - Fax:715-485-8450
Practice Address - Street 1:100 POLK COUNTY PLZ
Practice Address - Street 2:STE 50
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-9071
Practice Address - Country:US
Practice Address - Phone:715-485-8862
Practice Address - Fax:715-485-8450
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8078-120101YA0400X
WI15908-132101YA0400X
WI6332-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)