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General NPI Number Information
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NPI Number | 1255412714
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Entity Type | Organization
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Legal Business Name | MONTGOMERY COUNSELING CENTER
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 323 12TH AVE RD
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City | NAMPA
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State | ID
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Zip | 83686-5014
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Country | US
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Telephone | 208-463-0212
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Fax | 208-461-5452
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Provider Business Mailing Address
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Address Line | 323 12TH AVE RD
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City | NAMPA
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State | ID
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Zip | 83686-5014
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Country | US
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Telephone | 208-463-0212
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Fax | 208-461-5452
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Authorized Official
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Title or Position | LCSW
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Name | PHYLLIS MONTGOMERY
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Credential |
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Telephone | 208-463-0212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LCSW 712
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License Number State | ID
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