Provider Demographics
NPI:1548631294
Name:MONTGOMERY, KEYSHA MASHELLE I
Entity type:Individual
Prefix:MS
First Name:KEYSHA
Middle Name:MASHELLE
Last Name:MONTGOMERY
Suffix:I
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 1:551 W 125TH ST
Mailing Address - Street 2:STORE FRONT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-3433
Mailing Address - Country:US
Mailing Address - Phone:212-678-7188
Mailing Address - Fax:212-666-1583
Practice Address - Street 1:551 W 125TH ST
Practice Address - Street 2:STORE FRONT
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-3433
Practice Address - Country:US
Practice Address - Phone:212-678-7188
Practice Address - Fax:212-666-1583
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health