Provider Demographics
NPI:1720495526
Name:MONTGOMERY, CARL (MFT)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 MARKET ST
Mailing Address - Street 2:SUITE 942
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-3099
Mailing Address - Country:US
Mailing Address - Phone:415-577-8862
Mailing Address - Fax:
Practice Address - Street 1:870 MARKET ST
Practice Address - Street 2:SUITE 942
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-3099
Practice Address - Country:US
Practice Address - Phone:415-577-8862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC53867106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC53867OtherCALIFORNIA BOARD OF BEHAVIORAL SCIENCES