Provider Demographics
NPI:1275318073
Name:MONTGOMERY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:207 NW CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:OK
Mailing Address - Zip Code:74563-2546
Mailing Address - Country:US
Mailing Address - Phone:918-754-2891
Mailing Address - Fax:
Practice Address - Street 1:207 NW CEDAR ST
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:OK
Practice Address - Zip Code:74563-2546
Practice Address - Country:US
Practice Address - Phone:918-465-6833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator