Provider Demographics
NPI:1033623780
Name:MONTGOMERY-DIENER, AVERIE (PTA, LMT)
Entity Type:Individual
Prefix:
First Name:AVERIE
Middle Name:
Last Name:MONTGOMERY-DIENER
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2538 CAMINO ENTRADA STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4927
Mailing Address - Country:US
Mailing Address - Phone:505-424-1239
Mailing Address - Fax:
Practice Address - Street 1:2538 CAMINO ENTRAD SUITE 300
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507
Practice Address - Country:US
Practice Address - Phone:505-424-1239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4837225700000X
NMA-1328225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist