Provider Demographics
NPI:1316787229
Name:MONTGOMERY-WALKER, CAROLYN BEVERLY
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:BEVERLY
Last Name:MONTGOMERY-WALKER
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 1:10427 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-1645
Mailing Address - Country:US
Mailing Address - Phone:216-242-7443
Mailing Address - Fax:
Practice Address - Street 1:10427 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-1645
Practice Address - Country:US
Practice Address - Phone:216-741-2241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2305339-TRNE390200000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program