Provider Demographics
NPI:1609293257
Name:MONTIE, AMANDA MELISSA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MELISSA
Last Name:MONTIE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MELISSA
Other - Last Name:BRACKROG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:6699 ALVARADO RD
Mailing Address - Street 2:STE 2100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5238
Mailing Address - Country:US
Mailing Address - Phone:619-229-3909
Mailing Address - Fax:619-229-3902
Practice Address - Street 1:1360 BLAIR DR STE D
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1343
Practice Address - Country:US
Practice Address - Phone:410-672-8970
Practice Address - Fax:410-672-8973
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39215225100000X
MD26372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist