Provider Demographics
NPI:1093813107
Name:MONTGOMERY, SUSAN A (OT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
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:PO BOX 162904
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78716-2904
Mailing Address - Country:US
Mailing Address - Phone:512-306-1707
Mailing Address - Fax:512-306-7380
Practice Address - Street 1:4613 BEE CAVE RD STE 202
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-5212
Practice Address - Country:US
Practice Address - Phone:512-306-1707
Practice Address - Fax:512-306-7380
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103036225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81973TOtherBCBS
TX103036OtherSTATE BOARD