Healthcare Provider Details

I. General information

NPI: 1659409084
Provider Name (Legal Business Name): RUSSELL SCOTT MONTGOMERY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 6TH ST
LONGVIEW TX
75601-5567
US

IV. Provider business mailing address

300 RALPH ST
LONGVIEW TX
75605-1116
US

V. Phone/Fax

Practice location:
  • Phone: 903-297-1852
  • Fax: 903-297-8798
Mailing address:
  • Phone: 903-663-8598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19025
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: