Provider Demographics
NPI:1104155126
Name:MONTGOMERY, JOSEPH PAUL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:PAUL
Last Name:MONTGOMERY
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24715 LITTLE MACK AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3207
Mailing Address - Country:US
Mailing Address - Phone:586-777-9000
Mailing Address - Fax:586-777-0823
Practice Address - Street 1:24715 LITTLE MACK AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3207
Practice Address - Country:US
Practice Address - Phone:586-777-9000
Practice Address - Fax:586-777-0823
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011520101YP2500X
MI4704318966363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI75091042OtherBLUE CROSS