Provider Demographics
NPI:1083251342
Name:MONTGOMERY, SHANNON LEE (OT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 MCKAY CT STE 100
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5786
Mailing Address - Country:US
Mailing Address - Phone:330-965-3899
Mailing Address - Fax:330-965-3839
Practice Address - Street 1:835 MCKAY CT STE 100
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5786
Practice Address - Country:US
Practice Address - Phone:330-965-3899
Practice Address - Fax:330-965-3839
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT010847225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist