Provider Demographics
NPI:1255452082
Name:MONTGOMERY, GRETAL JEAN (MA)
Entity type:Individual
Prefix:MS
First Name:GRETAL
Middle Name:JEAN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 W 17TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:BC
Mailing Address - Zip Code:V5Y 2A2
Mailing Address - Country:CA
Mailing Address - Phone:778-883-8527
Mailing Address - Fax:
Practice Address - Street 1:751 E GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2529
Practice Address - Country:US
Practice Address - Phone:313-922-2222
Practice Address - Fax:313-922-8771
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014125103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist