Provider Demographics
NPI:1922513860
Name:MONTGOMERY, MIMOSE (LCSW)
Entity type:Individual
Prefix:MS
First Name:MIMOSE
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8910 MIRAMAR PKWY STE 305B
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-4100
Mailing Address - Country:US
Mailing Address - Phone:305-713-3261
Mailing Address - Fax:
Practice Address - Street 1:3160 POWERLINE RD
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-5911
Practice Address - Country:US
Practice Address - Phone:305-576-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW21589101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health