Provider Demographics
NPI:1235490145
Name:MONTGOMERY, MARY E (MS,RD,CDN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MS,RD,CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E 68TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:646-413-2783
Mailing Address - Fax:212-746-9456
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-3567
Practice Address - Fax:212-746-9456
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY749701133V00000X
NY007497-01133V00000X
NY007497133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered