Provider Demographics
NPI:1386007094
Name:MONTGOMERY, MADISON (LMHC)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:POLINICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 ROUTE 111
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3754
Mailing Address - Country:US
Mailing Address - Phone:631-920-8306
Mailing Address - Fax:
Practice Address - Street 1:11 ROUTE 111
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3754
Practice Address - Country:US
Practice Address - Phone:631-920-8300
Practice Address - Fax:631-920-8460
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY011205-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator