MEDICARE: MRS. MARY SUSAN KNOWLES MONTGOMERY M.ED., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA3436	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376626390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY SUSAN KNOWLES MONTGOMERY M.ED., CCC-SLP

Provider Business Mailing Address
First Line	:	1018 HAGLER DR
Second Line	:
City	:	NEPTUNE BEACH
State	:	FL
Zip	:	32266-3756
Country	:	US
Telephone Number	:	904-249-0685
Fax Number	:

Provider Business Practice Location Address
First Line	:	1018 HAGLER DR
Second Line	:
City	:	NEPTUNE BEACH
State	:	FL
Zip	:	32266-3756
Country	:	US
Telephone Number	:	904-249-0685
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	10/06/2011

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