MEDICARE: KIMBERLY G MONTGOMERY PHD HSPP

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	103T00000X	Psychologist	20040771A	IN

General Provider Information

NPI Number	:	1821170861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY G MONTGOMERY PHD HSPP

Provider Business Mailing Address
First Line	:	6296 RUCKER RD STE A
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4852
Country	:	US
Telephone Number	:	317-580-4007
Fax Number	:	833-244-0469

Provider Business Practice Location Address
First Line	:	6296 RUCKER RD STE A
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4852
Country	:	US
Telephone Number	:	317-580-4007
Fax Number	:	833-244-0469

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

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	10/30/2021

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