Provider Demographics
NPI:1770964256
Name:MONTEMAYOR, JOHANNA (PT)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:MONTEMAYOR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18530 AUTUMNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15400 TRENTON RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2075
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:502-657-7493
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225100000X
MI5501011410225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist