Provider Demographics
NPI:1669104006
Name:MCDANIEL, MONTAY TRE'VON II
Entity type:Individual
Prefix:
First Name:MONTAY
Middle Name:TRE'VON
Last Name:MCDANIEL
Suffix:II
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 1:9586 SUNFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CA
Mailing Address - Zip Code:95693-9739
Mailing Address - Country:US
Mailing Address - Phone:916-280-3275
Mailing Address - Fax:
Practice Address - Street 1:9586 SUNFLOWER RD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CA
Practice Address - Zip Code:95693-9739
Practice Address - Country:US
Practice Address - Phone:916-280-3275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer