Basic Information
| Provider Information | |||||||||
| NPI: | 1265778658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | MIKIELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON | ||||||||
| OtherFirstName: | MIKIELA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4909 ASHFORD DR | ||||||||
| Address2: | |||||||||
| City: | UPPER MARLBORO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207722776 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15005 HEALTH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207161017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018056070 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2012 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 24271 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.