MEDICARE: MRS. NIOKA FAWN MONTGOMERY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1043340391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NIOKA FAWN MONTGOMERY

Provider Business Mailing Address
First Line	:	6011 TROTWOOD AVE # A
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401-7009
Country	:	US
Telephone Number	:	931-560-3061
Fax Number	:	931-560-3062

Provider Business Practice Location Address
First Line	:	6011 TROTWOOD AVE # A
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401-7009
Country	:	US
Telephone Number	:	931-560-3061
Fax Number	:	931-560-3062

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/08/2007

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