Basic Information
| Provider Information | |||||||||
| NPI: | 1861790933 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEAN M. MONTY PHD PSYCHOLOGICAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14135 N CEDARBURG RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530971416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623772006 | ||||||||
| FaxNumber: | 2623775552 | ||||||||
| Practice Location | |||||||||
| Address1: | 14135 N CEDARBURG RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530971416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623772006 | ||||||||
| FaxNumber: | 2623775552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2011 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | MONTY | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2623772006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1880 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1417001579 | 05 | WI | MEDICAID |