Provider Demographics
NPI:1962411256
Name:MONTGOMERY, EDITH RENEE (PHD)
Entity type:Individual
Prefix:DR
First Name:EDITH
Middle Name:RENEE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 BRYANSTON CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-3883
Mailing Address - Country:US
Mailing Address - Phone:313-801-3270
Mailing Address - Fax:313-567-9855
Practice Address - Street 1:2131 BRYANSTON CRESCENT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3883
Practice Address - Country:US
Practice Address - Phone:313-801-3270
Practice Address - Fax:313-567-9855
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008150103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical