Basic Information
| Provider Information | |||||||||
| NPI: | 1932543733 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | EBONY | ||||||||
| MiddleName: | THERESA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PIERRE | ||||||||
| OtherFirstName: | EBONY | ||||||||
| OtherMiddleName: | THERESA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 555 TOWNER ST | ||||||||
| Address2: | P.O. BOX 915 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481985752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345443050 | ||||||||
| FaxNumber: | 7345442906 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 TOWNER ST. | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345443050 | ||||||||
| FaxNumber: | 7345442906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2013 | ||||||||
| LastUpdateDate: | 10/29/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401013178 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.