Provider Demographics
NPI:1497196166
Name:MONTGOMERY, KEVIN M (OT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 GOSS AVE APT 5101
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-2284
Mailing Address - Country:US
Mailing Address - Phone:270-577-7045
Mailing Address - Fax:
Practice Address - Street 1:946 GOSS AVE APT 5101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-2284
Practice Address - Country:US
Practice Address - Phone:270-577-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005502A225X00000X
KY167765225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist