Basic Information
| Provider Information | |||||||||
| NPI: | 1366630378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | TAMELA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2607 CADDO STE 6 | ||||||||
| Address2: | |||||||||
| City: | ARKADELPHIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702308217 | ||||||||
| FaxNumber: | 8702308201 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 HALBERT ST | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721042607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013324400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2007 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | P1405050 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1366630378 | 01 | AR | UNITED HEALTHCARE BCBS | OTHER | 1366630378 | 01 | AR | UNITED HEALTHCARE AND BLUE CROSS BLUE SHIELD | OTHER |