Individual
MS. MARY JEAN MONTGOMERY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCDCII, A.A.S.
Contact information
Practice address
732 BECKMAN STREET, DAYTON, OH 45410-2165
(937) 301-5678
Mailing address
732 BECKMAN STREET, DAYTON, OH 45410-2165
(937) 253-1680
(937) 253-1337
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
111042
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
106S00000X
AETNA
OH
01
—
600540025
AETNA
OH
Enumeration date
06/06/2018
Last updated
06/06/2018
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