Provider Demographics
NPI:1427211606
Name:MONTGOMERY, INGO D (MS, BA, LICDC, LSW)
Entity Type:Individual
Prefix:
First Name:INGO
Middle Name:D
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MS, BA, LICDC, LSW
Other - Prefix:
Other - First Name:MONTY
Other - Middle Name:D
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, BA, LICDC, LSW
Mailing Address - Street 1:835 N LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:OH
Mailing Address - Zip Code:45875-1216
Mailing Address - Country:US
Mailing Address - Phone:419-523-4300
Mailing Address - Fax:419-523-6188
Practice Address - Street 1:835 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:OH
Practice Address - Zip Code:45875-1216
Practice Address - Country:US
Practice Address - Phone:419-523-4300
Practice Address - Fax:419-523-6188
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH82777101YA0400X
OH00279041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical