Healthcare Provider Details

I. General information

NPI: 1689042574
Provider Name (Legal Business Name): STEPHANIE MONTGOMERY ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7920 BRUSH LAKE RD
NORTH LEWISBURG OH
43060-9617
US

IV. Provider business mailing address

1850 FORD RD
DELAWARE OH
43015-7816
US

V. Phone/Fax

Practice location:
  • Phone: 937-826-3102
  • Fax:
Mailing address:
  • Phone: 937-620-8669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: