Provider Demographics
NPI:1861645764
Name:MONTGOMERY, MILLIE
Entity Type:Individual
Prefix:MRS
First Name:MILLIE
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 1:2323 E PALMDALE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4957
Mailing Address - Country:US
Mailing Address - Phone:213-605-5227
Mailing Address - Fax:
Practice Address - Street 1:2323 E PALMDALE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4957
Practice Address - Country:US
Practice Address - Phone:661-948-2042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA993901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health