Healthcare Provider Details

I. General information

NPI: 1093322927
Provider Name (Legal Business Name): BROOKLYN MONTGOMERY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 W MAIN ST STE C
TRUMANN AR
72472-2634
US

IV. Provider business mailing address

2809 FOREST HOME RD
JONESBORO AR
72401-5320
US

V. Phone/Fax

Practice location:
  • Phone: 870-483-0068
  • Fax: 870-483-0066
Mailing address:
  • Phone: 866-972-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10064-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: