Provider Demographics
NPI:1740574474
Name:THOMAS, MONTINA MARIE
Entity Type:Individual
Prefix:
First Name:MONTINA
Middle Name:MARIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 SHAMROCK RD
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-6487
Mailing Address - Country:US
Mailing Address - Phone:270-945-1603
Mailing Address - Fax:
Practice Address - Street 1:714 SHAMROCK RD
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-6487
Practice Address - Country:US
Practice Address - Phone:270-945-1603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-28
Last Update Date:2011-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201126605222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist