MEDICARE: MR. FREDRICK KENYETTA 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	101YA0400X	Addiction (Substance Use Disorder) Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265758957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FREDRICK KENYETTA MONTGOMERY

Provider Business Mailing Address
First Line	:	3621 N KELLEY AVE
Second Line	:	SUITE 100
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-4520
Country	:	US
Telephone Number	:	405-524-5525
Fax Number	:	405-204-6963

Provider Business Practice Location Address
First Line	:	3621 N KELLEY AVE
Second Line	:	SUITE 100
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-4520
Country	:	US
Telephone Number	:	405-524-5525
Fax Number	:	405-204-6963

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

Provider Enumeration Date	:	04/20/2010
Last Update Date	:	01/25/2026

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