Provider Demographics
NPI:1437268125
Name:MONTGOMERY, ROBERT W (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WEATHERSTONE DR STE 530
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7006
Mailing Address - Country:US
Mailing Address - Phone:770-591-9552
Mailing Address - Fax:800-218-8249
Practice Address - Street 1:107 WEATHERSTONE DR
Practice Address - Street 2:SUITE 530
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188
Practice Address - Country:US
Practice Address - Phone:770-591-9552
Practice Address - Fax:800-218-8249
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-03-1376103K00000X
GAPSY001980103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000637777FMedicaid
GA000637777EMedicaid
GA003216493AMedicaid
GA58-2574174OtherALL PRIV INSURANCE