Healthcare Provider Details

I. General information

NPI: 1831337120
Provider Name (Legal Business Name): JANEEN MONTGOMERY-PETERSON PSY. D., LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANEEN MONTGOMERY PSY. D., LP

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 01/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7270 FORESTVIEW LN N STE 150
MAPLE GROVE MN
55369-5568
US

IV. Provider business mailing address

7270 FORESTVIEW LN N STE 150
MAPLE GROVE MN
55369-5568
US

V. Phone/Fax

Practice location:
  • Phone: 763-416-4167
  • Fax: 763-416-4137
Mailing address:
  • Phone: 763-416-4167
  • Fax: 763-416-4137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4750
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: