Basic Information
| Provider Information | |||||||||
| NPI: | 1609293257 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTIE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MELISSA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRACKROG | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | MELISSA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6699 ALVARADO RD | ||||||||
| Address2: | STE 2100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921205238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192293909 | ||||||||
| FaxNumber: | 6192293902 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 BLAIR DR STE D | ||||||||
| Address2: | |||||||||
| City: | ODENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211131343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106728970 | ||||||||
| FaxNumber: | 4106728973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2014 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 39215 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.