Provider Demographics
NPI:1265978225
Name:MONTANYE, MIA REID (OT)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:REID
Last Name:MONTANYE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1975
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-1975
Mailing Address - Country:US
Mailing Address - Phone:904-619-5831
Mailing Address - Fax:866-225-4350
Practice Address - Street 1:10660 OLD SAINT AUGUSTINE RD STE PT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-1076
Practice Address - Country:US
Practice Address - Phone:904-619-5831
Practice Address - Fax:866-225-4350
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT15256225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIW927YMedicare UPIN
FLIW927ZMedicare PIN