Provider Demographics
NPI:1497235212
Name:MONTGOMERY, MISTI MICHELE
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:MICHELE
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 1:822 NADINE LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2313
Mailing Address - Country:US
Mailing Address - Phone:469-441-1164
Mailing Address - Fax:
Practice Address - Street 1:822 NADINE LN
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-2313
Practice Address - Country:US
Practice Address - Phone:469-441-1164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2056603225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant