Basic Information
| Provider Information | |||||||||
| NPI: | 1639523855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTES | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | CARLOS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MONTES | ||||||||
| OtherFirstName: | ROBERT | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSY. D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 129 MEDICINE HORSE DR | ||||||||
| Address2: | |||||||||
| City: | TO'HAJIILEE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059082307 | ||||||||
| FaxNumber: | 5059082572 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 B VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | ACOMA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525300 | ||||||||
| FaxNumber: | 5055525490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 34858 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 34858 | 01 | TX | LICENSE PSYCHOLOGIST | OTHER | H3451 | 05 | NM | MEDICAID |