Provider Demographics
NPI:1487023073
Name:MONTGOMERY, ROXANNE
Entity Type:Individual
Prefix:
First Name:ROXANNE
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 1:603 FULTON RD APT E41
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-2217
Mailing Address - Country:US
Mailing Address - Phone:407-489-0369
Mailing Address - Fax:
Practice Address - Street 1:40352 BLOSSOM VALLEY LN
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-4563
Practice Address - Country:US
Practice Address - Phone:183-261-0437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-24
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3926103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst