Provider Demographics
NPI:1639217920
Name:MONTGOMERY, NICOLETTA LARISSA
Entity Type:Individual
Prefix:MS
First Name:NICOLETTA
Middle Name:LARISSA
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 TOOK DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-1943
Mailing Address - Country:US
Mailing Address - Phone:615-480-0328
Mailing Address - Fax:
Practice Address - Street 1:132 TOOK DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-1943
Practice Address - Country:US
Practice Address - Phone:615-480-0328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health