MEDICARE: STEPHANIE MONTGOMERY ED.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist

General Provider Information

NPI Number	:	1689042574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE MONTGOMERY ED.S.

Provider Business Mailing Address
First Line	:	1850 FORD RD
Second Line	:
City	:	DELAWARE
State	:	OH
Zip	:	43015-7816
Country	:	US
Telephone Number	:	937-620-8669
Fax Number	:

Provider Business Practice Location Address
First Line	:	7920 BRUSH LAKE RD
Second Line	:
City	:	NORTH LEWISBURG
State	:	OH
Zip	:	43060-9617
Country	:	US
Telephone Number	:	937-826-3102
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2015
Last Update Date	:	09/09/2015

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