Provider Demographics
NPI:1548460439
Name:MONTAGUE, SUSAN (LCP, LCAC, LMLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:LCP, LCAC, LMLP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:509 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-2353
Mailing Address - Country:US
Mailing Address - Phone:800-423-1342
Mailing Address - Fax:785-628-3113
Practice Address - Street 1:645 E IRON AVE STE C
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-2697
Practice Address - Country:US
Practice Address - Phone:800-423-1342
Practice Address - Fax:785-628-3113
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS050101Y00000X
KS2811103T00000X
KS011103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200435200BMedicaid