Provider Demographics
NPI:1407330194
Name:MONTGOMERY, BRANDIE
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 FOURTH ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:77434
Mailing Address - Country:US
Mailing Address - Phone:832-332-0813
Mailing Address - Fax:
Practice Address - Street 1:206 N SMITH ST
Practice Address - Street 2:
Practice Address - City:WEIMAR
Practice Address - State:TX
Practice Address - Zip Code:78962-1814
Practice Address - Country:US
Practice Address - Phone:979-725-8564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2134351225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant