=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437545449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY MONTGOMERY M.A., LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2015
-----------------------------------------------------
Last Update Date | 08/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 559 16TH ST
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-507-1763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 559 16TH ST
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94612-1515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-507-1763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 82418
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------