Provider Demographics
NPI:1073815221
Name:MONTGOMERY, COLLEEN LESLEY (LCPC)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:LESLEY
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SOLOMONS RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1268
Mailing Address - Country:US
Mailing Address - Phone:410-336-4950
Mailing Address - Fax:410-793-5569
Practice Address - Street 1:103 SOLOMONS RIDGE CT
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1268
Practice Address - Country:US
Practice Address - Phone:410-336-4950
Practice Address - Fax:410-793-5569
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-21
Last Update Date:2010-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3540101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health