Basic Information
| Provider Information | |||||||||
| NPI: | 1093322927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | BROOKLYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2809 FOREST HOME RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724015320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669721268 | ||||||||
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| Practice Location | |||||||||
| Address1: | 809 W MAIN ST STE C | ||||||||
| Address2: | |||||||||
| City: | TRUMANN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724722634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704830068 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2020 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 10064-M | AR | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.