Provider Demographics
NPI:1649423849
Name:MONTGOMERY, BRANDIS K (PT)
Entity Type:Individual
Prefix:
First Name:BRANDIS
Middle Name:K
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BRANDIS
Other - Middle Name:K
Other - Last Name:BOLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3455 HIGHWAY 81
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-9138
Mailing Address - Country:US
Mailing Address - Phone:770-554-0665
Mailing Address - Fax:770-554-0685
Practice Address - Street 1:611 HIGHWAY 74 S
Practice Address - Street 2:STE 720
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3081
Practice Address - Country:US
Practice Address - Phone:770-632-6800
Practice Address - Fax:770-632-6060
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005353225100000X
GA009891225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist