Provider Demographics
NPI:1295865772
Name:MONTGOMERY, DONALD RAY (AS, RSST MHFA, CCHW,)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:RAY
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:AS, RSST MHFA, CCHW,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PETERBORO ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2722
Mailing Address - Country:US
Mailing Address - Phone:313-831-3160
Mailing Address - Fax:
Practice Address - Street 1:10 PETERBORO ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2722
Practice Address - Country:US
Practice Address - Phone:313-831-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68030624871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical