Provider Demographics
NPI:1790934792
Name:MONTGOMERY, WILLIAM R (M A , LPC, CCJP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:R
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:M A , LPC, CCJP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 HARTFORD ST # 1F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1917
Mailing Address - Country:US
Mailing Address - Phone:314-771-6742
Mailing Address - Fax:314-436-1887
Practice Address - Street 1:4320 HARTFORD ST # 1F
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-1917
Practice Address - Country:US
Practice Address - Phone:314-771-6742
Practice Address - Fax:314-436-1887
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018058101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional