Basic Information
| Provider Information | |||||||||
| NPI: | 1003155516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTAGUE | ||||||||
| FirstName: | STACIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW, BSW,LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 3RD FLOOR HOME BASED SERVICES | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035750466 | ||||||||
| FaxNumber: | 2035751817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2013 | ||||||||
| LastUpdateDate: | 08/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 1874 | CT | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | NOT ELIGIBLE | 01 | CT | MHN TRICARE | OTHER | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | 008060347 | 05 | CT | MEDICAID | 060669107 | 01 | CT | UBH CONNECTICARE WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH OXFORD HEALTH LIBERTY/FREEDOM WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY | OTHER | NOT ELIGIBLE | 01 | CT | MHN TRICARENORTH | OTHER | NOT ELIGIBLE | 01 | CT | MHN-MANAGED HEALTH NETWORK | OTHER | 060669107 | 01 | CT | HEALTHYCT WELLMORE GRP/FACILITY | OTHER | 13671439 | 01 | CT | CAQH | OTHER | D3392029 WATERBURY | 01 | CT | BEACON HEALTH STRATEGIES | OTHER |