Healthcare Provider Details

I. General information

NPI: 1720704075
Provider Name (Legal Business Name): DEVON MONTGOMERY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 PARK HILL DR
FREDERICKSBURG VA
22401-3377
US

IV. Provider business mailing address

501 PARK HILL DR
FREDERICKSBURG VA
22401-3377
US

V. Phone/Fax

Practice location:
  • Phone: 540-656-2786
  • Fax: 540-372-3510
Mailing address:
  • Phone: 540-656-2786
  • Fax: 540-372-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306606157
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: