Provider Demographics
NPI:1972895175
Name:MONTGOMERY, KEOSHA DV (MA, LPCA)
Entity Type:Individual
Prefix:MISS
First Name:KEOSHA
Middle Name:DV
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 IVY MEADOW DR APT 1217
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-9041
Mailing Address - Country:US
Mailing Address - Phone:704-726-8366
Mailing Address - Fax:
Practice Address - Street 1:635 COX RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3424
Practice Address - Country:US
Practice Address - Phone:704-691-7561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health