Provider Demographics
NPI:1740005131
Name:MONTGOMERY, SAMUEL DAVID (PTA)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:DAVID
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 1:1340 WESTBANK EXPY
Mailing Address - Street 2:
Mailing Address - City:WESTWEGO
Mailing Address - State:LA
Mailing Address - Zip Code:70094-4712
Mailing Address - Country:US
Mailing Address - Phone:504-371-4226
Mailing Address - Fax:504-371-4228
Practice Address - Street 1:1340 WESTBANK EXPY
Practice Address - Street 2:
Practice Address - City:WESTWEGO
Practice Address - State:LA
Practice Address - Zip Code:70094-4712
Practice Address - Country:US
Practice Address - Phone:504-371-4226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA11912225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant