Healthcare Provider Details

I. General information

NPI: 1528722238
Provider Name (Legal Business Name): CLINT A MONTGOMERY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6432 SAINT JOSEPHS AVE NW
ALBUQUERQUE NM
87120-3709
US

IV. Provider business mailing address

1321 E POPLAR ST
DEMING NM
88030-4807
US

V. Phone/Fax

Practice location:
  • Phone: 860-307-4212
  • Fax:
Mailing address:
  • Phone: 575-546-5951
  • Fax: 575-546-5994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number242567
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: