Provider Demographics
NPI:1841787967
Name:MONTGOMERY, CHARLES (LPC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 LIME QUARRY RD STE 212
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8976
Mailing Address - Country:US
Mailing Address - Phone:512-569-5328
Mailing Address - Fax:
Practice Address - Street 1:190 LIME QUARRY RD STE 212
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-8976
Practice Address - Country:US
Practice Address - Phone:512-569-5328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3786101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional