=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508756925
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA ELIZABETH MONTGOMERY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2025
-----------------------------------------------------
Last Update Date | 07/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 W IRONWOOD DR STE 102
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-4903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-966-4376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4079 N ABBEY RD
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83815-7802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-771-4126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MAS-4282
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------