Provider Demographics
NPI:1184965568
Name:MONTGOMERY, MYRANDA
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:
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 1:2280 BENTON DR.
Mailing Address - Street 2:BUILDING C SUITE B
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-5362
Mailing Address - Country:US
Mailing Address - Phone:530-242-2031
Mailing Address - Fax:530-241-4192
Practice Address - Street 1:2280 BENTON DR.
Practice Address - Street 2:BUILDING C SUITE B
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-5362
Practice Address - Country:US
Practice Address - Phone:530-242-2031
Practice Address - Fax:530-241-4192
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker