Healthcare Provider Details

I. General information

NPI: 1659592277
Provider Name (Legal Business Name): AYNGI MONTGOMERY M.ED M.DIV LPC NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 N HIGHWAY 66 SUITE B
CATOOSA OK
74015-2460
US

IV. Provider business mailing address

PO BOX 700082
TULSA OK
74170-0082
US

V. Phone/Fax

Practice location:
  • Phone: 918-852-9644
  • Fax:
Mailing address:
  • Phone: 918-852-9644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4100
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: