Provider Demographics
NPI:1013208867
Name:MONTGOMERY, LAQUITA SPIVEY
Entity Type:Individual
Prefix:
First Name:LAQUITA
Middle Name:SPIVEY
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
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 230
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:FL
Mailing Address - Zip Code:32949-0230
Mailing Address - Country:US
Mailing Address - Phone:321-676-6122
Mailing Address - Fax:321-676-6382
Practice Address - Street 1:325 CLEMATIS ST
Practice Address - Street 2:116
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-4610
Practice Address - Country:US
Practice Address - Phone:321-676-6122
Practice Address - Fax:321-676-6382
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-01-0573103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst