Provider Demographics
NPI:1821191123
Name:MONTGOMERY, ROBERT H (LICSW CADAC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:H
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:LICSW CADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 EUCLID AVENUE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890
Mailing Address - Country:US
Mailing Address - Phone:781-721-1373
Mailing Address - Fax:781-938-0406
Practice Address - Street 1:400 WEST CUMMINGS PK
Practice Address - Street 2:SUITE 3300
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801
Practice Address - Country:US
Practice Address - Phone:781-938-1138
Practice Address - Fax:781-938-0406
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0873AD101YA0400X
MA103356104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMOPO1818Medicare ID - Type Unspecified