Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 7334775-3501 | UT |
NPI | 1003005166 |
---|---|
Provider Name | Mr. Michael Andrew Montgomery |
First Address | Harrisville, UT 84404-3537 |
Second Address | Harrisville, UT 84404-3537 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/10/2007 |
Last Update Date | 11/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
260022408 | RAILROAD MEDICARE (01) | UT |
876000308007 | (05) | UT |