Provider Demographics
NPI:1699013342
Name:MONTGOMERY, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92531-0549
Mailing Address - Country:US
Mailing Address - Phone:951-294-5879
Mailing Address - Fax:951-294-5806
Practice Address - Street 1:2055 N PERRIS BLVD STE G6
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2516
Practice Address - Country:US
Practice Address - Phone:951-940-6061
Practice Address - Fax:951-940-1691
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)