Provider Demographics
NPI:1598847360
Name:MONTECILLO, MARIA LEAH E (PT)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LEAH E
Last Name:MONTECILLO
Suffix:
Gender:F
Credentials:PT
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 369
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-0369
Mailing Address - Country:US
Mailing Address - Phone:864-329-4211
Mailing Address - Fax:678-840-2112
Practice Address - Street 1:213 E BUTLER RD BLDG E2
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2172
Practice Address - Country:US
Practice Address - Phone:864-346-0391
Practice Address - Fax:678-840-2112
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2846225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ342798395Medicare ID - Type UnspecifiedMEDICARE # WITH MMGI