=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659389302
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN E MONTGOMERY LCSW-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3930 KNOWLES AVE SUITE 200
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-2428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-897-8815
-----------------------------------------------------
Fax | 301-897-8815
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10108 EDWARD AVE
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-897-8815
-----------------------------------------------------
Fax | 301-897-8815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 07751
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------