Provider Demographics
NPI:1851478564
Name:MONTGOMERY, MARK ALYN (LPC, LISAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALYN
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:LPC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4554 E INVERNESS AVE # C-108
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4639
Mailing Address - Country:US
Mailing Address - Phone:480-330-5031
Mailing Address - Fax:480-926-2326
Practice Address - Street 1:4554 E. INVERNESS AVE., C-108
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4639
Practice Address - Country:US
Practice Address - Phone:480-330-5031
Practice Address - Fax:480-926-2326
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-1677101YA0400X
AZLPC-2087101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPC-2087OtherLICENSED PROF. COUNSELOR
AZLISAC-1677OtherLIC. IND. SUB. ABUSE COUN