Provider Demographics
NPI:1376970046
Name:MONTGOMERY, LAEL (CAC)
Entity Type:Individual
Prefix:
First Name:LAEL
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 GOVERNMENT ST
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-5922
Mailing Address - Country:US
Mailing Address - Phone:225-925-4282
Mailing Address - Fax:225-925-1987
Practice Address - Street 1:2455 WOODDALE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-7569
Practice Address - Country:US
Practice Address - Phone:225-922-3169
Practice Address - Fax:225-922-3225
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1121101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)