Healthcare Provider Details

I. General information

NPI: 1023210911
Provider Name (Legal Business Name): LORETTA BAKER-MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2007
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 NORTH ELM STREET
MOUNTAIN VIEW MO
65548-7109
US

IV. Provider business mailing address

PO BOX 1100
WEST PLAINS MO
65775-1100
US

V. Phone/Fax

Practice location:
  • Phone: 417-934-2273
  • Fax: 417-934-2332
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2003017994
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: