Healthcare Provider Details

I. General information

NPI: 1720112899
Provider Name (Legal Business Name): JOANNE C.S. MONTGOMERY LCSW, RMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 MOODY CT STE 201
THOUSAND OAKS CA
91360-7427
US

IV. Provider business mailing address

3411 CLOUDCROFT DR
MALIBU CA
90265-5631
US

V. Phone/Fax

Practice location:
  • Phone: 805-241-7473
  • Fax: 805-777-3574
Mailing address:
  • Phone: 310-459-1006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS17757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: