Provider Demographics
NPI:1598236556
Name:MONTAGUE, GRACE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2895 SE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-7644
Mailing Address - Country:US
Mailing Address - Phone:561-385-4963
Mailing Address - Fax:
Practice Address - Street 1:3500 CLUBHOUSE LN
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-6002
Practice Address - Country:US
Practice Address - Phone:561-745-5925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1868225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant