Provider Demographics
NPI:1992914873
Name:MONTGOMERY, CAROL S (MFT)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:S
Last Name:MONTGOMERY
Suffix:
Gender:F
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:PO BOX 4124
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-8124
Mailing Address - Country:US
Mailing Address - Phone:909-592-2090
Mailing Address - Fax:909-592-4149
Practice Address - Street 1:448 E FOOTHILL BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1205
Practice Address - Country:US
Practice Address - Phone:909-592-2090
Practice Address - Fax:909-592-4149
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35018106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist