Basic Information
| Provider Information | |||||||||
| NPI: | 1649423849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | BRANDIS | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLIN | ||||||||
| OtherFirstName: | BRANDIS | ||||||||
| OtherMiddleName: | K | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3455 HIGHWAY 81 | ||||||||
| Address2: | |||||||||
| City: | LOGANVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300529138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705540665 | ||||||||
| FaxNumber: | 7705540685 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 HIGHWAY 74 S | ||||||||
| Address2: | STE 720 | ||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302693081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706326800 | ||||||||
| FaxNumber: | 7706326060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2008 | ||||||||
| LastUpdateDate: | 02/24/2017 | ||||||||
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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 | 005353 | KY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 009891 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.