Provider Demographics
NPI:1871828509
Name:ELLEN PAIGE MONTGOMERY, LLC
Entity Type:Organization
Organization Name:ELLEN PAIGE MONTGOMERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:PAIGE
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-413-3833
Mailing Address - Street 1:1807 OVER LAKE DR SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1777
Mailing Address - Country:US
Mailing Address - Phone:678-413-3833
Mailing Address - Fax:770-385-1832
Practice Address - Street 1:1807 OVER LAKE DR SE
Practice Address - Street 2:SUITE C
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1777
Practice Address - Country:US
Practice Address - Phone:678-413-3833
Practice Address - Fax:770-385-1832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4154101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA200566262AMedicaid