Provider Demographics
NPI:1669029880
Name:MONTGOMERY, JAMES EUGENE
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EUGENE
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:EUGENE
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JAMES E MONTGOMERY
Mailing Address - Street 1:7733 N MOUNTAIN ASH WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-4359
Mailing Address - Country:US
Mailing Address - Phone:435-229-7352
Mailing Address - Fax:
Practice Address - Street 1:910 W STATE ST APT 1
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2046
Practice Address - Country:US
Practice Address - Phone:801-349-9606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11233930101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health