Basic Information
| Provider Information | |||||||||
| NPI: | 1467745182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15405 LANSDOWNE RD STE C | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927820201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142587710 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15405 LANSDOWNE RD STE C | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927820201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142587710 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2011 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 118173 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.