Provider Demographics
NPI:1801614854
Name:MONTGOMERY, KRISTIAN
Entity type:Individual
Prefix:MRS
First Name:KRISTIAN
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1193 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:PMB# 107
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5332
Mailing Address - Country:US
Mailing Address - Phone:504-275-8333
Mailing Address - Fax:
Practice Address - Street 1:3267 SW CONSTELLATION RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-4637
Practice Address - Country:US
Practice Address - Phone:504-275-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist