Provider Demographics
NPI:1316106107
Name:MONTGOMERY, PHYLLIS (LCSW)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5014
Mailing Address - Country:US
Mailing Address - Phone:208-463-0212
Mailing Address - Fax:208-461-5452
Practice Address - Street 1:323 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5014
Practice Address - Country:US
Practice Address - Phone:208-463-0212
Practice Address - Fax:208-461-5452
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 712101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002743500Medicaid