Provider Demographics
NPI:1477759306
Name:MONTGOMERY, AMY SUSAN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUSAN
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 1:1135 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-3566
Mailing Address - Country:US
Mailing Address - Phone:660-646-7305
Mailing Address - Fax:660-646-7305
Practice Address - Street 1:1135 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-3566
Practice Address - Country:US
Practice Address - Phone:660-646-7305
Practice Address - Fax:660-646-7305
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002765101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional