Healthcare Provider Details

I. General information

NPI: 1497164099
Provider Name (Legal Business Name): SHEENA GENICE MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 DOUGLAS AVE STE 208
ALTAMONTE SPRINGS FL
32714-5206
US

IV. Provider business mailing address

8048 CLOVERGLEN CIR
ORLANDO FL
32818-8212
US

V. Phone/Fax

Practice location:
  • Phone: 407-830-6412
  • Fax: 407-830-8413
Mailing address:
  • Phone: 561-315-7119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMT 1915
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: