Provider Demographics
NPI:1144653130
Name:DEMONTEGNAC, ALICIA VICTORIA (MA)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:VICTORIA
Last Name:DEMONTEGNAC
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4085 RAVINA TER
Mailing Address - Street 2:
Mailing Address - City:ST. JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-240-4631
Mailing Address - Fax:
Practice Address - Street 1:4085 RAVINA TER
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9655
Practice Address - Country:US
Practice Address - Phone:269-240-4631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health