Healthcare Provider Details

I. General information

NPI: 1831751452
Provider Name (Legal Business Name): NYESHA MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 BEAVER RUIN RD STE 500
NORCROSS GA
30093-2813
US

IV. Provider business mailing address

276 TECUMSEH LN
MARY ESTHER FL
32569-2225
US

V. Phone/Fax

Practice location:
  • Phone: 248-220-7980
  • Fax:
Mailing address:
  • Phone: 678-517-0632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-91080
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-74650
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: