Provider Demographics
NPI:1770050163
Name:MONTGOMERY, ANGELA NICHOLE (MOT, OTR)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:NICHOLE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:NICHOLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR
Mailing Address - Street 1:4402 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-2717
Mailing Address - Country:US
Mailing Address - Phone:260-273-3021
Mailing Address - Fax:
Practice Address - Street 1:215 DAVIS RD
Practice Address - Street 2:
Practice Address - City:OSSIAN
Practice Address - State:IN
Practice Address - Zip Code:46777-9230
Practice Address - Country:US
Practice Address - Phone:260-622-7821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006258A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist