{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "MONTGOMERY PSYCHOLOGICAL SERVICES, PLLC",
"LastName": null,
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"NamePrefix": null,
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"Credential": null,
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"FirstLineMailingAddress": "32841 MIDDLEBELT RD",
"SecondLineMailingAddress": "SUITE 409",
"MailingAddressCityName": "FARMINGTON HILLS",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48334-1771",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "248-539-3950",
"MailingAddressFaxNumber": "313-567-9855",
"FirstLinePracticeLocationAddress": "2131 BRYANSTON CRESCENT ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DETROIT",
"PracticeLocationAddressStateName": "MI",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "248-539-3950",
"PracticeLocationAddressFaxNumber": "313-567-9855",
"EnumerationDate": "09/15/2009",
"LastUpdateDate": "10/04/2010",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MONTGOMERY",
"AuthorizedOfficialFirstName": "EDITH",
"AuthorizedOfficialMiddleName": "R",
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"AuthorizedOfficialCredential": "PH.D CLINICAL PSYCHO",
"AuthorizedOfficialTelephoneNumber": "248-539-3950",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Community/Behavioral Health Agency",
"LicenseNumber": "6301008150",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}