Provider Demographics
NPI:1447614532
Name:MONTGOMERY, LAURETTA
Entity Type:Individual
Prefix:MS
First Name:LAURETTA
Middle Name:
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 1:9403 MANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2552
Mailing Address - Country:US
Mailing Address - Phone:318-861-8938
Mailing Address - Fax:
Practice Address - Street 1:904 MISSISSIPPI CIR
Practice Address - Street 2:
Practice Address - City:VIVIAN
Practice Address - State:LA
Practice Address - Zip Code:71082-2552
Practice Address - Country:US
Practice Address - Phone:318-936-3641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1014M0800X101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health