Provider Demographics
NPI:1073185286
Name:MONTGOMERY, MIRANDA KATELYNN (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:KATELYNN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6070 DANNY AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:VA
Mailing Address - Zip Code:24084-2156
Mailing Address - Country:US
Mailing Address - Phone:540-616-5505
Mailing Address - Fax:
Practice Address - Street 1:5286 ALEXANDER RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-3650
Practice Address - Country:US
Practice Address - Phone:540-674-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119009116225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist