Provider Demographics
NPI:1114244753
Name:MONTGOMERY, JOE EDWARD
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:EDWARD
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 1:3570 GUILFORD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2240
Mailing Address - Country:US
Mailing Address - Phone:313-720-1787
Mailing Address - Fax:
Practice Address - Street 1:3570 GUILFORD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-2240
Practice Address - Country:US
Practice Address - Phone:313-720-1787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator