MEDICARE: MONTGOMERY PSYCHOLOGICAL SERVICES, PLLC

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	251S00000X	Community/Behavioral Health Agency	6301008150	MI

General Provider Information

NPI Number	:	1225361884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTGOMERY PSYCHOLOGICAL SERVICES, PLLC

Provider Business Mailing Address
First Line	:	32841 MIDDLEBELT RD
Second Line	:	SUITE 409
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-1771
Country	:	US
Telephone Number	:	248-539-3950
Fax Number	:	313-567-9855

Provider Business Practice Location Address
First Line	:	2131 BRYANSTON CRESCENT ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-3883
Country	:	US
Telephone Number	:	248-539-3950
Fax Number	:	313-567-9855

Authorized Official
Title or Position	:	OWNER
Name	:	DR. EDITH R MONTGOMERY
Credential	:	PH.D CLINICAL PSYCHO
Telephone Number	:	248-539-3950

Provider Enumeration Date	:	09/15/2009
Last Update Date	:	10/04/2010

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