Provider Demographics
NPI:1275330581
Name:BROCK, MONTGOMERY LEE (LCDC, LPC)
Entity type:Individual
Prefix:
First Name:MONTGOMERY
Middle Name:LEE
Last Name:BROCK
Suffix:
Gender:
Credentials:LCDC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3839 BRIARGROVE LN APT 11203
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6388
Mailing Address - Country:US
Mailing Address - Phone:903-714-4463
Mailing Address - Fax:
Practice Address - Street 1:213 US HIGHWAY 259 N
Practice Address - Street 2:
Practice Address - City:ORE CITY
Practice Address - State:TX
Practice Address - Zip Code:75683-2106
Practice Address - Country:US
Practice Address - Phone:903-714-4463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health