Provider Demographics
NPI:1255752481
Name:MONTGOMERY, KASEY
Entity type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MILL SIDE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7019
Mailing Address - Country:US
Mailing Address - Phone:815-440-4758
Mailing Address - Fax:
Practice Address - Street 1:1286 JUNGERMANN RD
Practice Address - Street 2:STE G
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-6967
Practice Address - Country:US
Practice Address - Phone:815-440-4758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013034795104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker