Provider Demographics
NPI:1164557062
Name:MONTGOMERY, ALYSHA MAULDIN (MS)
Entity Type:Individual
Prefix:
First Name:ALYSHA
Middle Name:MAULDIN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 COUNTY ROAD 392
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35057-4088
Mailing Address - Country:US
Mailing Address - Phone:256-734-8158
Mailing Address - Fax:
Practice Address - Street 1:212 4TH AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-3662
Practice Address - Country:US
Practice Address - Phone:256-735-1727
Practice Address - Fax:256-735-1211
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2044235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51509017OtherBLUE CROSS BLUE SHIELD AL