Provider Demographics
NPI:1770823189
Name:MONTANEZ, KIESHA (PT)
Entity Type:Individual
Prefix:
First Name:KIESHA
Middle Name:
Last Name:MONTANEZ
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 1:4000 MITCHELLVILLE RD
Mailing Address - Street 2:STE A404
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3137
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:4000 MITCHELLVILLE RD
Practice Address - Street 2:STE A404
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3137
Practice Address - Country:US
Practice Address - Phone:410-939-8530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist