Provider Demographics
NPI:1295226611
Name:MONTGOMERY, TORI CAMILLE (BSW,MSW)
Entity Type:Individual
Prefix:MISS
First Name:TORI
Middle Name:CAMILLE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:BSW,MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-3550
Mailing Address - Fax:336-277-1825
Practice Address - Street 1:175 KIMEL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6951
Practice Address - Country:US
Practice Address - Phone:336-718-3550
Practice Address - Fax:336-277-1825
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0139001041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health