Healthcare Provider Details

I. General information

NPI: 1992259808
Provider Name (Legal Business Name): EMILY MONTANA MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 HAYTER ST
NACOGDOCHES TX
75962-0001
US

IV. Provider business mailing address

712 HAYTER ST
NACOGDOCHES TX
75962-0001
US

V. Phone/Fax

Practice location:
  • Phone: 936-468-5802
  • Fax: 936-468-4052
Mailing address:
  • Phone: 936-468-5802
  • Fax: 936-468-4052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT5808
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000020951
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: