Provider Demographics
NPI:1457346769
Name:MONTGOMERY, ALTHEA
Entity Type:Individual
Prefix:MS
First Name:ALTHEA
Middle Name:
Last Name:MONTGOMERY
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 1:10459 TARA BEACH CIR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-7955
Mailing Address - Country:US
Mailing Address - Phone:678-230-7272
Mailing Address - Fax:770-478-5214
Practice Address - Street 1:10459 TARA BEACH CIR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-7955
Practice Address - Country:US
Practice Address - Phone:678-230-7272
Practice Address - Fax:770-478-5214
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-005430225X00000X, 225XP0200X
GA2534225XP0200X
FLOT0007107225X00000X
AL1586225X00000X
FL1263226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000902195AMedicaid