Basic Information
Provider Information
NPI: 1003155516
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MONTAGUE
FirstName: STACIA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MSW, BSW,LMSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000X1874CTY Behavioral Health & Social Service ProvidersSocial Worker 

ID Information
IDTypeStateIssuerDescription
06066910701CTUNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITYOTHER
1367143901CTCAQHOTHER
NOT ELIGIBLE01CTMHN-MANAGED HEALTH NETWORKOTHER
NOT ELIGIBLE01CTMHN TRICAREOTHER
06066910701CTUBH-UNITED HEALTHCARE WELLMORE GRP/FACILITYOTHER
PENDING01CTAETNA BEHAVIORAL HEALTHOTHER
06066910701CTANTHEM BCBS OF CT WELLMORE GRP/FACILITYOTHER
D3392029 WATERBURY01CTBEACON HEALTH STRATEGIESOTHER
NOT ELIGIBLE01CTMHN TRICARENORTHOTHER
PENDING01CTCIGNA BEHAVIORAL HEALTHOTHER
06066910701CTUBH CONNECTICARE WELLMORE GRP/FACILITYOTHER
00806034705CT MEDICAID
06066910701CTHEALTHYCT WELLMORE GRP/FACILITYOTHER
06066910701CTUBH OXFORD HEALTH LIBERTY/FREEDOM WELLMORE GRP/FACILITYOTHER


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