Provider Demographics
NPI:1528538451
Name:MONTGOMERY, ALEXANDRIA (MA)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 E 84TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-9513
Mailing Address - Country:US
Mailing Address - Phone:312-885-4621
Mailing Address - Fax:
Practice Address - Street 1:8419 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619
Practice Address - Country:US
Practice Address - Phone:312-885-4621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1699078766Medicaid