Basic Information
| Provider Information | |||||||||
| NPI: | 1669696605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MONTGOMERY | ||||||||
| OtherFirstName: | JUDY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524330061 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 943 W ANDREWS AVE STE H | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275362562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524330061 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 03/27/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C008305 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | SW2977 | FL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | Z051F | 01 | FL | BCBSFL | OTHER |