Basic Information
| Provider Information | |||||||||
| NPI: | 1558857102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTELLANO | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ACSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 529 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900131511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136296281 | ||||||||
| FaxNumber: | 3233807591 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900131511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136296281 | ||||||||
| FaxNumber: | 3233807591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2018 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW91682 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | ACSW91682 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.