Basic Information
| Provider Information | |||||||||
| NPI: | 1326278144 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAMELLA MONTGOMERY PH D PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4123 OKEMOS RD | ||||||||
| Address2: | SUITE 14 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488642818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173477736 | ||||||||
| FaxNumber: | 5173474644 | ||||||||
| Practice Location | |||||||||
| Address1: | 4123 OKEMOS RD | ||||||||
| Address2: | SUITE 14 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488642818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173477736 | ||||||||
| FaxNumber: | 5173474644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 10/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
| AuthorizedOfficialFirstName: | PAMELLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5173477736 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801000545 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.