Healthcare Provider Details

I. General information

NPI: 1164147484
Provider Name (Legal Business Name): ALEXIS MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 ALEXANDER BELL DR STE 200
COLUMBIA MD
21046-2105
US

IV. Provider business mailing address

4798 CEDAR NECK RD
MILFORD DE
19963-4339
US

V. Phone/Fax

Practice location:
  • Phone: 302-723-2294
  • Fax:
Mailing address:
  • Phone: 302-723-2294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA2064
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: