Provider Demographics
NPI:1184221913
Name:MONTGOMERY, BRANDON (DPT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-824-9335
Practice Address - Street 1:6022 HARVEY ST STE H
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-8802
Practice Address - Country:US
Practice Address - Phone:231-799-8883
Practice Address - Fax:231-799-8884
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist