Basic Information
| Provider Information | |||||||||
| NPI: | 1598274045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTAVON | ||||||||
| FirstName: | KELLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 LONG MEADOW CLARK RD | ||||||||
| Address2: | |||||||||
| City: | LUCASVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456489066 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456623944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403547702 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2017 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | C1901755 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.