Provider Demographics
NPI:1992521793
Name:MONTANA, MAXINE
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:MONTANA
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 1:5324 STREAM STONE AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4385
Mailing Address - Country:US
Mailing Address - Phone:505-718-5473
Mailing Address - Fax:
Practice Address - Street 1:5324 STREAM STONE AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4385
Practice Address - Country:US
Practice Address - Phone:505-718-5473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician