Healthcare Provider Details

I. General information

NPI: 1316787229
Provider Name (Legal Business Name): CAROLYN BEVERLY MONTGOMERY-WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10427 DETROIT AVE
CLEVELAND OH
44102-1645
US

IV. Provider business mailing address

10427 DETROIT AVE
CLEVELAND OH
44102-1645
US

V. Phone/Fax

Practice location:
  • Phone: 216-741-2241
  • Fax:
Mailing address:
  • Phone: 216-242-7443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberC.2305339-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: