Provider Demographics
NPI:1811085806
Name:MONTGOMERY, MYLES BRADLEY (LCSW)
Entity type:Individual
Prefix:MR
First Name:MYLES
Middle Name:BRADLEY
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:LCSW
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1511 CORPORATE WAY
Mailing Address - Street 2:STE 200
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3890
Mailing Address - Country:US
Mailing Address - Phone:916-422-2301
Mailing Address - Fax:916-422-2515
Practice Address - Street 1:1511 CORPORATE WAY
Practice Address - Street 2:STE 200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-3890
Practice Address - Country:US
Practice Address - Phone:916-422-2301
Practice Address - Fax:916-422-2515
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA25863104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker