Healthcare Provider Details

I. General information

NPI: 1851835151
Provider Name (Legal Business Name): MALLORY MONTGOMERY MS, ATR-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 W GRAND BLVD
DETROIT MI
48202-2610
US

IV. Provider business mailing address

2800 W GRAND BLVD
DETROIT MI
48202-2610
US

V. Phone/Fax

Practice location:
  • Phone: 133-556-8188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number17-250
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: