Provider Demographics
NPI:1275912834
Name:MONTGOMERY, MARISSA (CASAC-T)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W 125TH ST
Mailing Address - Street 2:11TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4516
Mailing Address - Country:US
Mailing Address - Phone:212-864-4128
Mailing Address - Fax:212-662-9193
Practice Address - Street 1:55 W 125TH ST
Practice Address - Street 2:11TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4516
Practice Address - Country:US
Practice Address - Phone:212-864-4128
Practice Address - Fax:212-662-9193
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31027101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health