Provider Demographics
NPI:1770795304
Name:MONTGOMERY, VICTORIA ILENE
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ILENE
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 1:1874 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3457
Mailing Address - Country:US
Mailing Address - Phone:909-386-0523
Mailing Address - Fax:
Practice Address - Street 1:1874 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3457
Practice Address - Country:US
Practice Address - Phone:909-386-0523
Practice Address - Fax:909-386-0529
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAII055360418101YA0400X
CA171M00000X
CA061298-II101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator