Healthcare Provider Details

I. General information

NPI: 1609713916
Provider Name (Legal Business Name): LAUDORIA B MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 ADAMS ST
QUINCY IL
62301-5337
US

IV. Provider business mailing address

634 ADAMS ST
QUINCY IL
62301-5337
US

V. Phone/Fax

Practice location:
  • Phone: 848-565-1069
  • Fax:
Mailing address:
  • Phone: 848-565-1069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberM53252202938
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: