Provider Demographics
NPI:1225401144
Name:MONTGOMERY, LYNETTE SUZANNE (CASAC)
Entity Type:Individual
Prefix:MRS
First Name:LYNETTE
Middle Name:SUZANNE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HALSTEAD RD
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3405
Mailing Address - Country:US
Mailing Address - Phone:607-345-0255
Mailing Address - Fax:
Practice Address - Street 1:380 FREEVILLE RD
Practice Address - Street 2:
Practice Address - City:FREEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13068-9684
Practice Address - Country:US
Practice Address - Phone:607-844-6493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29787101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)