Provider Demographics
NPI:1730503772
Name:MONTAGNA, MARY ELIZABETH (PT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:MONTAGNA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:RATHBONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:163 W AVENIDA DE LOS LOBOS MARINOS
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4359
Mailing Address - Country:US
Mailing Address - Phone:714-299-9642
Mailing Address - Fax:
Practice Address - Street 1:163 W AVENIDA DE LOS LOBOS MARINOS
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4359
Practice Address - Country:US
Practice Address - Phone:714-299-9642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist