Provider Demographics
NPI:1275730095
Name:MONTGOMERY, ERICA JEAN (OT)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:JEAN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9118
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55480-9118
Mailing Address - Country:US
Mailing Address - Phone:865-243-8152
Mailing Address - Fax:865-692-2352
Practice Address - Street 1:1050 N JAMES M CAMPBELL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-2754
Practice Address - Country:US
Practice Address - Phone:931-490-1325
Practice Address - Fax:931-490-1369
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2562225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ027309Medicaid