Provider Demographics
NPI:1285126052
Name:MONTGOMERY, MARY JEAN (LCDCII, AAS)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JEAN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LCDCII, AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 BECKMAN STREET
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410-2165
Mailing Address - Country:US
Mailing Address - Phone:937-253-1680
Mailing Address - Fax:937-253-1337
Practice Address - Street 1:732 BECKMAN STREET
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-2165
Practice Address - Country:US
Practice Address - Phone:937-301-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH111042106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH106S00000XOtherAETNA
OH600540025OtherAETNA