Basic Information
| Provider Information | |||||||||
| NPI: | 1184117343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 191 SNOW APPLE LN | ||||||||
| Address2: | |||||||||
| City: | DAVISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484239139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488027909 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7300 DIXIE HWY STE 1000 | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489222300 | ||||||||
| FaxNumber: | 2489222304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2018 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401000856 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.