Provider Demographics
NPI:1043342587
Name:MONTGOMERY, CYNTHIA ANN (LPTA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:MONTGOMERY
Other - Last Name:FOUTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPTA
Mailing Address - Street 1:2710 WILLING AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-3034
Mailing Address - Country:US
Mailing Address - Phone:817-223-5529
Mailing Address - Fax:
Practice Address - Street 1:2710 WILLING AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-3034
Practice Address - Country:US
Practice Address - Phone:817-223-5529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2019188171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor