Provider Demographics
NPI:1184950222
Name:MONTGOMERY INDIVIDUAL AND FAMILY THERAPY, LLC
Entity type:Organization
Organization Name:MONTGOMERY INDIVIDUAL AND FAMILY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AYNGI
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:918-852-9644
Mailing Address - Street 1:PO BOX 700082
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-0082
Mailing Address - Country:US
Mailing Address - Phone:918-852-9644
Mailing Address - Fax:
Practice Address - Street 1:10306 N 138TH EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4665
Practice Address - Country:US
Practice Address - Phone:918-852-9644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-25
Last Update Date:2009-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4100251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health