Provider Demographics
NPI:1124594106
Name:MONTGOMERY, RACHAEL (MFT)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
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 1:420 MCKINLEY ST
Mailing Address - Street 2:STE 111 BOX 615
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-6504
Mailing Address - Country:US
Mailing Address - Phone:714-584-9700
Mailing Address - Fax:
Practice Address - Street 1:1101 CALIFORNIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-6472
Practice Address - Country:US
Practice Address - Phone:714-584-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT106917103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA83-1928780OtherIRS