Provider Demographics
NPI:1770780660
Name:MONTGOMERY, DONNA MIA (MPH,OTR)
Entity type:Individual
Prefix:MISS
First Name:DONNA
Middle Name:MIA
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MPH,OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 N CENTRAL AVE APT 12P
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1717
Mailing Address - Country:US
Mailing Address - Phone:602-680-9564
Mailing Address - Fax:
Practice Address - Street 1:7540 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7967
Practice Address - Country:US
Practice Address - Phone:888-873-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2812225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist