Provider Demographics
NPI:1811072218
Name:MONTGOMERY, SUSAN L (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 FOX RD STE E
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3367
Mailing Address - Country:US
Mailing Address - Phone:865-405-2653
Mailing Address - Fax:865-531-3948
Practice Address - Street 1:135 FOX RD STE E
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3367
Practice Address - Country:US
Practice Address - Phone:865-405-2653
Practice Address - Fax:865-531-3948
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1932103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3686626Medicaid
TN3686626Medicare PIN