MEDICARE: DR. EDITH RENEE MONTGOMERY PH.D

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	103TC0700X	Clinical Psychologist	6301008150	MI

General Provider Information

NPI Number	:	1962411256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDITH RENEE MONTGOMERY PH.D

Provider Business Mailing Address
First Line	:	2131 BRYANSTON CRESCENT ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-3883
Country	:	US
Telephone Number	:	313-801-3270
Fax Number	:	313-567-9855

Provider Business Practice Location Address
First Line	:	2131 BRYANSTON CRESCENT ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-3883
Country	:	US
Telephone Number	:	313-801-3270
Fax Number	:	313-567-9855

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

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/08/2007

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