Provider Demographics
NPI:1669696605
Name:MONTGOMERY, JUDY (LCSW)
Entity type:Individual
Prefix:MS
First Name:JUDY
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JUDY
Other - Middle Name:
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:284 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1894
Mailing Address - Country:US
Mailing Address - Phone:252-433-0061
Mailing Address - Fax:
Practice Address - Street 1:943 W ANDREWS AVE STE H
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2562
Practice Address - Country:US
Practice Address - Phone:252-433-0061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0083051041C0700X
FLSW29771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ051FOtherBCBSFL
FLZ8817AMedicare ID - Type Unspecified