Healthcare Provider Details

I. General information

NPI: 1417071077
Provider Name (Legal Business Name): DWAN T MONTGOMERY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 W RIDGE RD
APACHE JUNCTION AZ
85120-0206
US

IV. Provider business mailing address

1214 W RIDGE RD
APACHE JUNCTION AZ
85120-0206
US

V. Phone/Fax

Practice location:
  • Phone: 843-494-1157
  • Fax:
Mailing address:
  • Phone: 843-494-1157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number16040
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15169
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: