Healthcare Provider Details

I. General information

NPI: 1710652136
Provider Name (Legal Business Name): KIM K MONTGOMERY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3736 EUBANK BLVD NE STE B1
ALBUQUERQUE NM
87111-3583
US

IV. Provider business mailing address

PO BOX 91345
ALBUQUERQUE NM
87199-1345
US

V. Phone/Fax

Practice location:
  • Phone: 505-293-2881
  • Fax: 888-506-2110
Mailing address:
  • Phone: 505-507-0862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC-08816
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: