Provider Demographics
NPI:1326868720
Name:MONTGOMERY, CHRISTIAN SIDNEY MAXWELL
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:SIDNEY MAXWELL
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 ALEXANDER LN
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-5034
Mailing Address - Country:US
Mailing Address - Phone:706-587-2319
Mailing Address - Fax:
Practice Address - Street 1:1110 13TH ST STE D
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2246
Practice Address - Country:US
Practice Address - Phone:706-780-1704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician