Provider Demographics
NPI:1457429128
Name:MONTGOMERY, MICHAEL SCOTT
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
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 641268
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-0304
Mailing Address - Country:US
Mailing Address - Phone:270-745-1120
Mailing Address - Fax:270-745-1156
Practice Address - Street 1:1110 WILKINSON TRCE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-3402
Practice Address - Country:US
Practice Address - Phone:270-796-6850
Practice Address - Fax:270-781-8228
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1822235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYGROUP# 91011148Medicaid
KYGROUP #184501Medicare ID - Type Unspecified