Provider Demographics
NPI:1730729781
Name:MONTELLO, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MONTELLO
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 1:6410 SCHMIDT LN APT C202
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-1949
Mailing Address - Country:US
Mailing Address - Phone:425-463-5711
Mailing Address - Fax:
Practice Address - Street 1:103 SHORELINE PKWY STE 201
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-5584
Practice Address - Country:US
Practice Address - Phone:415-453-9980
Practice Address - Fax:415-453-6137
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1770656704Medicaid
CA1083069447Medicaid