Provider Demographics
NPI:1669658886
Name:MONTGOMERY, WILLIAM SEWELL (PTA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SEWELL
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W MORTON AVE
Mailing Address - Street 2:SUITE 16A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3287
Mailing Address - Country:US
Mailing Address - Phone:217-245-4640
Mailing Address - Fax:
Practice Address - Street 1:901 W MORTON AVE
Practice Address - Street 2:SUITE 16A
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3287
Practice Address - Country:US
Practice Address - Phone:217-245-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant