Healthcare Provider Details

I. General information

NPI: 1285101345
Provider Name (Legal Business Name): LASHANDA MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 11/17/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5170 E 65TH ST STE 106
INDIANAPOLIS IN
46220-4992
US

IV. Provider business mailing address

12683 LARGO DR
FISHERS IN
46037-8189
US

V. Phone/Fax

Practice location:
  • Phone: 317-986-6755
  • Fax:
Mailing address:
  • Phone: 317-366-8249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: