=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992178396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M & M COUNSELING & ASSESSMENT SERVICES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2015
-----------------------------------------------------
Last Update Date | 11/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 DENA DR
-----------------------------------------------------
City | SAN ANGELO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76904-5014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-223-0786
-----------------------------------------------------
Fax | 325-617-4196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 DENA DR
-----------------------------------------------------
City | SAN ANGELO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76904-5014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-223-0786
-----------------------------------------------------
Fax | 325-617-4196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM ATTERBURY MONTGOMERY
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 325-223-0786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 25043
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------