Provider Demographics
NPI:1619192986
Name:MONTGOMERY, MELINDA M (MS, LPC, LPA)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:M
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MS, LPC, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 DENA DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-5014
Mailing Address - Country:US
Mailing Address - Phone:325-223-0786
Mailing Address - Fax:325-617-4196
Practice Address - Street 1:2501 DENA DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-5014
Practice Address - Country:US
Practice Address - Phone:325-223-0786
Practice Address - Fax:325-617-4196
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18065101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6232LCOtherBLUECROSS BLUESHIELD OF T
TX157588801Medicaid