MEDICARE: SALLIE E MONTGOMERY PSYD, LP

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	LP3354	MN

General Provider Information

NPI Number	:	1962436469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLIE E MONTGOMERY PSYD, LP

Provider Business Mailing Address
First Line	:	6515 PINNACLE DR
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55346-1906
Country	:	US
Telephone Number	:	952-934-2212
Fax Number	:

Provider Business Practice Location Address
First Line	:	5905 GOLDEN VALLEY RD
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4463
Country	:	US
Telephone Number	:	763-225-4052
Fax Number	:

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/08/2007

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