Provider Demographics
NPI:1922141589
Name:MONTGOMERY, KELLIE ANNE (CADAC II)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANNE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:OLIVEHURST
Mailing Address - State:CA
Mailing Address - Zip Code:95961-0002
Mailing Address - Country:US
Mailing Address - Phone:530-822-7320
Mailing Address - Fax:530-822-7470
Practice Address - Street 1:1965 LIVE OAK BLVD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-8828
Practice Address - Country:US
Practice Address - Phone:530-822-7200
Practice Address - Fax:530-822-3296
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA8561306101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)