Provider Demographics
NPI:1902236854
Name:MONTALVO, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:MONTALVO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 OLD RIDGEBURY RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5128
Mailing Address - Country:US
Mailing Address - Phone:203-792-4515
Mailing Address - Fax:203-748-2604
Practice Address - Street 1:419 WHALLEY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3019
Practice Address - Country:US
Practice Address - Phone:203-285-6475
Practice Address - Fax:203-748-2604
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000667101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1174607253OtherMIDWESTERN CONNECTICUT COUNCIL ON ALCOHOLISM
CT008044401Medicaid