Provider Demographics
NPI:1003225913
Name:MONTGOMERY, BRETT (PTA)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 GINA DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8807
Mailing Address - Country:US
Mailing Address - Phone:502-232-5606
Mailing Address - Fax:
Practice Address - Street 1:303 N HURSTBOURNE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5185
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03218225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant