Provider Demographics
NPI:1770899742
Name:MONTGOMERY, MONIQUE M (LCSW, LCDP)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:M
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LCSW, LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 BALLANTYNE COMMONS PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3174
Mailing Address - Country:US
Mailing Address - Phone:704-446-0271
Mailing Address - Fax:704-348-4057
Practice Address - Street 1:7825 BALLANTYNE COMMONS PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3174
Practice Address - Country:US
Practice Address - Phone:704-446-0271
Practice Address - Fax:704-348-4057
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0096551041C0700X
RILCDP00473101YA0400X
RICSW015061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1274Medicaid
NC1770899742Medicaid
NCQ51152AMedicare PIN