Provider Demographics
NPI:1831822287
Name:MONTEZ, ANSELMO JESUS
Entity type:Individual
Prefix:
First Name:ANSELMO
Middle Name:JESUS
Last Name:MONTEZ
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 1:11731 TELEGRAPH RD STE G
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-6819
Mailing Address - Country:US
Mailing Address - Phone:562-942-8256
Mailing Address - Fax:
Practice Address - Street 1:11731 TELEGRAPH RD STE G
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-6819
Practice Address - Country:US
Practice Address - Phone:562-942-8256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA118765104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty