Provider Demographics
NPI:1710099189
Name:MONTGOMERY, GARY P (MA, LPC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:P
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30472 23 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-1844
Mailing Address - Country:US
Mailing Address - Phone:586-863-4000
Mailing Address - Fax:
Practice Address - Street 1:30472 23 MILE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-1844
Practice Address - Country:US
Practice Address - Phone:586-863-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002971101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor