Provider Demographics
NPI:1164080479
Name:MONTGOMERY, BRIANNA NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:NICOLE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 VICTORY PKWY APT 712
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-1672
Mailing Address - Country:US
Mailing Address - Phone:513-377-6728
Mailing Address - Fax:
Practice Address - Street 1:6200 PFEIFFER RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-5862
Practice Address - Country:US
Practice Address - Phone:513-985-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-01
Last Update Date:2019-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023423225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH102154285-00OtherCARE SOURCE