Provider Demographics
NPI:1104579309
Name:MONTGOMERY, SHAMICIA C
Entity type:Individual
Prefix:
First Name:SHAMICIA
Middle Name:C
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 SOUTH BLVD UNIT 162
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48303-7007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8255 HALL RD
Practice Address - Street 2:STE D
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5528
Practice Address - Country:US
Practice Address - Phone:248-972-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451016396101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional