Basic Information
Provider Information
NPI: 1003005166
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MONTGOMERY
FirstName: MICHAEL
MiddleName: ANDREW
NamePrefix: MR.
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 811 N HARRISVILLE RD
Address2:  
City: HARRISVILLE
State: UT
PostalCode: 844043537
CountryCode: US
TelephoneNumber: 8013991818
FaxNumber:  
Practice Location
Address1: 811 N HARRISVILLE RD
Address2:  
City: HARRISVILLE
State: UT
PostalCode: 844043537
CountryCode: US
TelephoneNumber: 8013991818
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/15/2007
LastUpdateDate: 06/11/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X7334775-3501UTY Behavioral Health & Social Service ProvidersSocial WorkerClinical

ID Information
IDTypeStateIssuerDescription
26002240801UTRAILROAD MEDICAREOTHER
87600030800705UT MEDICAID


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