Provider Demographics
NPI:1154849990
Name:MONTGOMERY, MARISSA C (LSW)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:C
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:902 GALLIA ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4139
Practice Address - Country:US
Practice Address - Phone:740-529-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1701290104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker