Provider Demographics
NPI:1700452133
Name:MONTGOMERY, MAIA ELIZABETH
Entity Type:Individual
Prefix:
First Name:MAIA
Middle Name:ELIZABETH
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 1:562 MONTGOMERY ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-5522
Mailing Address - Country:US
Mailing Address - Phone:603-998-4785
Mailing Address - Fax:
Practice Address - Street 1:562 MONTGOMERY ST APT 3
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-5522
Practice Address - Country:US
Practice Address - Phone:603-998-4785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician