Provider Demographics
NPI:1356089577
Name:MONTGOMERY, KEISHA NICOLE (PRSS)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:NICOLE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 COW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:OMAR
Mailing Address - State:WV
Mailing Address - Zip Code:25638-9516
Mailing Address - Country:US
Mailing Address - Phone:304-928-5656
Mailing Address - Fax:
Practice Address - Street 1:101 LOGAN ST STE 200
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-0016
Practice Address - Country:US
Practice Address - Phone:304-235-3570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)