Provider Demographics
NPI:1265682470
Name:MONTGOMERY, MICHELLE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 N 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-6224
Mailing Address - Country:US
Mailing Address - Phone:602-264-3824
Mailing Address - Fax:
Practice Address - Street 1:5619 N 47TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-6224
Practice Address - Country:US
Practice Address - Phone:602-264-3824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0803224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant