Basic Information
| Provider Information | |||||||||
| NPI: | 1366104416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTARULI | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 BOUSH ST | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235101626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2026741269 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 W 19TH ST | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235172218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576227017 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2021 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0904013340 | 01 | VA | LICENSE | OTHER |