1457708638 NPI number — MS. MONICA MONTANO BOOTH PMHNP

Table of content: MS. MONICA MONTANO BOOTH PMHNP (NPI 1457708638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457708638 NPI number — MS. MONICA MONTANO BOOTH PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOOTH
Provider First Name:
MONICA
Provider Middle Name:
MONTANO
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457708638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16620 N. 40TH STREET
Provider Second Line Business Mailing Address:
SUITE E-1
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-464-9576
Provider Business Mailing Address Fax Number:
480-428-0475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13331 W INDIAN SCHOOL RD
Provider Second Line Business Practice Location Address:
STE B203
Provider Business Practice Location Address City Name:
LITCHFIELD PARK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-269-3990
Provider Business Practice Location Address Fax Number:
623-269-3924
Provider Enumeration Date:
05/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP8874 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 226022 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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