Provider Demographics
NPI:1417071077
Name:MONTGOMERY, DWAN T (LPC)
Entity Type:Individual
Prefix:MS
First Name:DWAN
Middle Name:T
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LPC
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 14
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289-0014
Mailing Address - Country:US
Mailing Address - Phone:704-808-0400
Mailing Address - Fax:336-791-4480
Practice Address - Street 1:1309 NORTHUP ST
Practice Address - Street 2:SUITE D
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5611
Practice Address - Country:US
Practice Address - Phone:704-808-0400
Practice Address - Fax:336-791-4480
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6488101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005887Medicaid