Provider Demographics
NPI:1245779891
Name:MONTGOMERY, TAKARA DASHELLE (LLPC)
Entity Type:Individual
Prefix:
First Name:TAKARA
Middle Name:DASHELLE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17272 OLYMPIA
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-2166
Mailing Address - Country:US
Mailing Address - Phone:313-205-3300
Mailing Address - Fax:
Practice Address - Street 1:17272 OLYMPIA
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-2166
Practice Address - Country:US
Practice Address - Phone:313-205-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015824101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional