Provider Demographics
NPI:1689042574
Name:MONTGOMERY, STEPHANIE (EDS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 FORD RD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-7816
Mailing Address - Country:US
Mailing Address - Phone:937-620-8669
Mailing Address - Fax:
Practice Address - Street 1:7920 BRUSH LAKE RD
Practice Address - Street 2:
Practice Address - City:NORTH LEWISBURG
Practice Address - State:OH
Practice Address - Zip Code:43060-9617
Practice Address - Country:US
Practice Address - Phone:937-826-3102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool