MEDICARE: CHARISSE MICHELLE 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	374J00000X	Doula	123251217	IL

General Provider Information

NPI Number	:	1942873617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARISSE MICHELLE MONTGOMERY

Provider Business Mailing Address
First Line	:	1274 BAYBROOK CT
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-7980
Country	:	US
Telephone Number	:	618-250-7792
Fax Number	:

Provider Business Practice Location Address
First Line	:	1274 BAYBROOK CT
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-7980
Country	:	US
Telephone Number	:	618-250-7792
Fax Number	:

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

Provider Enumeration Date	:	07/21/2021
Last Update Date	:	12/04/2025

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Directions to “ CHARISSE MICHELLE MONTGOMERY ” Practice Location

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