Provider Demographics
NPI:1932543733
Name:MONTGOMERY, EBONY THERESA (LPC)
Entity Type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:THERESA
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:EBONY
Other - Middle Name:THERESA
Other - Last Name:PIERRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:555 TOWNER ST
Mailing Address - Street 2:P.O. BOX 915
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5752
Mailing Address - Country:US
Mailing Address - Phone:734-544-3050
Mailing Address - Fax:734-544-2906
Practice Address - Street 1:555 TOWNER ST.
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198
Practice Address - Country:US
Practice Address - Phone:734-544-3050
Practice Address - Fax:734-544-2906
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013178101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional