Provider Demographics
NPI:1144673195
Name:COSTANZA-MONTELLANO, SARAH
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:COSTANZA-MONTELLANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 MCHENRY VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4308
Mailing Address - Country:US
Mailing Address - Phone:209-550-5850
Mailing Address - Fax:209-544-0487
Practice Address - Street 1:1700 MCHENRY VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-550-5850
Practice Address - Fax:209-544-0487
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health