Provider Demographics
NPI:1578073995
Name:MONTGMERY, MICHAEL ROBERT
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:MONTGMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 TOWER DR UNIT 346
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-5828
Mailing Address - Country:US
Mailing Address - Phone:224-507-3005
Mailing Address - Fax:
Practice Address - Street 1:1801 TOWER DR UNIT 346
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5828
Practice Address - Country:US
Practice Address - Phone:224-507-3005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILPENDING101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty