Provider Demographics
NPI:1992861678
Name:MONTAGNO, MICHELLE JEANNE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:JEANNE
Last Name:MONTAGNO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2057 DIVISADERO STREET
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-2112
Mailing Address - Country:US
Mailing Address - Phone:415-745-1910
Mailing Address - Fax:415-255-2101
Practice Address - Street 1:2057 DIVISADERO STREET
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2112
Practice Address - Country:US
Practice Address - Phone:415-745-1910
Practice Address - Fax:415-255-2101
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CAPSY24919103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist