Provider Demographics
NPI:1487821856
Name:SERDAN GROUP, LLC
Entity Type:Organization
Organization Name:SERDAN GROUP, LLC
Other - Org Name:KIMBERLY G. MONTGOMERY, PH.D. HSPP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, HSPP
Authorized Official - Phone:317-580-4007
Mailing Address - Street 1:10585 N MERIDIAN ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1069
Mailing Address - Country:US
Mailing Address - Phone:317-580-4007
Mailing Address - Fax:317-580-4010
Practice Address - Street 1:10585 N MERIDIAN ST
Practice Address - Street 2:SUITE 340
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1069
Practice Address - Country:US
Practice Address - Phone:317-580-4007
Practice Address - Fax:317-580-4010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040771261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN180940Medicare PIN