Provider Demographics
NPI:1912109190
Name:MONTGOMERY, SUE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:MARIE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:MARIE
Other - Last Name:MANDEVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28860 S 595 CIR
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7752
Mailing Address - Country:US
Mailing Address - Phone:469-432-3203
Mailing Address - Fax:
Practice Address - Street 1:2225 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-1620
Practice Address - Country:US
Practice Address - Phone:918-542-4101
Practice Address - Fax:918-542-4410
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT4765174400000X
OK4765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist