MEDICARE: GRACE MALLIS MONTGOMERY

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

General Provider Information

NPI Number	:	1063297430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE MALLIS MONTGOMERY

Provider Business Mailing Address
First Line	:	12831 TIKAL WAY
Second Line	:
City	:	TRINITY
State	:	FL
Zip	:	34655-7253
Country	:	US
Telephone Number	:	727-386-3896
Fax Number	:

Provider Business Practice Location Address
First Line	:	4707 W GANDY BLVD STE 3
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-3310
Country	:	US
Telephone Number	:	813-728-6601
Fax Number	:

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

Provider Enumeration Date	:	08/25/2023
Last Update Date	:	08/25/2023

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Directions to “ GRACE MALLIS MONTGOMERY ” Practice Location

Language	Start Address	Practice Location

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