Provider Demographics
NPI:1437773223
Name:MONTGOMERY, THERSEA LYNN
Entity Type:Individual
Prefix:
First Name:THERSEA
Middle Name:LYNN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12604 W 131ST ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-5020
Mailing Address - Country:US
Mailing Address - Phone:913-526-6614
Mailing Address - Fax:
Practice Address - Street 1:5750 W 95TH ST STE 220
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66207-2969
Practice Address - Country:US
Practice Address - Phone:913-444-5602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3605101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional