Provider Demographics
NPI:1689643116
Name:MONTGOMERY, MICHAEL WAYNE (MA, ATC, LAT, LMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MA, ATC, LAT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CRYSTAL SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-8203
Mailing Address - Country:US
Mailing Address - Phone:502-460-4557
Mailing Address - Fax:
Practice Address - Street 1:102 CRYSTAL SPRINGS DR
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-8203
Practice Address - Country:US
Practice Address - Phone:502-460-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000895A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer