Provider Demographics
NPI:1922588060
Name:MONTGOMERY, DOMINIQUE DEVERAUX
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:DEVERAUX
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 1:570 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-2334
Mailing Address - Country:US
Mailing Address - Phone:313-224-0715
Mailing Address - Fax:
Practice Address - Street 1:570 CLINTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2334
Practice Address - Country:US
Practice Address - Phone:313-224-0715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010997531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical