Provider Demographics
NPI:1518152610
Name:MONTGOMERY, MARK ALAN (LPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:MONTGOMERY
Suffix:
Gender:M
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:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:WEIR
Mailing Address - State:TX
Mailing Address - Zip Code:78674-0295
Mailing Address - Country:US
Mailing Address - Phone:512-445-7974
Mailing Address - Fax:
Practice Address - Street 1:1011 W 31ST ST
Practice Address - Street 2:SUITE 24
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-2099
Practice Address - Country:US
Practice Address - Phone:512-445-7974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17050101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional