Provider Demographics
NPI:1619026051
Name:MONTGOMERY, CRAIG STANLEY (PHD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:STANLEY
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13203 SE 172ND AVE STE 166-233
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-8737
Mailing Address - Country:US
Mailing Address - Phone:503-661-7733
Mailing Address - Fax:503-661-7890
Practice Address - Street 1:1217 NE BURNSIDE RD STE 801
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5770
Practice Address - Country:US
Practice Address - Phone:503-661-7733
Practice Address - Fax:503-661-7890
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR530103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR102938Medicare ID - Type Unspecified
R58679Medicare UPIN