Provider Demographics
NPI:1871713305
Name:MONTGOMERY, GABRIELLA HELAINE-WOLF (MC)
Entity type:Individual
Prefix:MRS
First Name:GABRIELLA
Middle Name:HELAINE-WOLF
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-0269
Mailing Address - Country:US
Mailing Address - Phone:602-550-0591
Mailing Address - Fax:
Practice Address - Street 1:3411 N 5TH AVE
Practice Address - Street 2:#209
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3811
Practice Address - Country:US
Practice Address - Phone:602-550-0591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-12649101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor