Provider Demographics
NPI:1790226173
Name:MONTGOMERY, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:693 S 400 E
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-2924
Mailing Address - Country:US
Mailing Address - Phone:435-723-1799
Mailing Address - Fax:
Practice Address - Street 1:693 S 400 E
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-2924
Practice Address - Country:US
Practice Address - Phone:435-723-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor