Provider Demographics
NPI:1700397957
Name:MONTGOMERY, EMILY (LICDC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 FINDLAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-4148
Mailing Address - Country:US
Mailing Address - Phone:740-351-2718
Mailing Address - Fax:
Practice Address - Street 1:750 CROSS POINTE RD STE D
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-6692
Practice Address - Country:US
Practice Address - Phone:614-407-6513
Practice Address - Fax:937-998-1118
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161495101YA0400X
KYE.1800903101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)