Provider Demographics
NPI:1114099298
Name:MONTGOMERY, JOHN L (LMHC, LMFT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:L
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:LMHC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 1ST PL NW
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-3271
Mailing Address - Country:US
Mailing Address - Phone:425-392-0277
Mailing Address - Fax:425-392-2509
Practice Address - Street 1:55 1ST PL NW
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-3271
Practice Address - Country:US
Practice Address - Phone:425-392-0277
Practice Address - Fax:425-392-2509
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005140101YM0800X
WALF00001249106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
169565OtherVALUE OPTIONS ID #
4594458OtherAETNA US HEALTHCARE #
MO9010OtherREGENCE PIN#