Provider Demographics
NPI:1043340391
Name:MONTGOMERY, NIOKA FAWN
Entity type:Individual
Prefix:MRS
First Name:NIOKA
Middle Name:FAWN
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 1:6011 TROTWOOD AVE # A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-7009
Mailing Address - Country:US
Mailing Address - Phone:931-560-3061
Mailing Address - Fax:931-560-3062
Practice Address - Street 1:6011 TROTWOOD AVE # A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-7009
Practice Address - Country:US
Practice Address - Phone:931-560-3061
Practice Address - Fax:931-560-3062
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health