Provider Demographics
NPI:1861905150
Name:MONTGOMERY, GABRIELLE
Entity type:Individual
Prefix:
First Name:GABRIELLE
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 1:3139 S SPECK AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1881
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11661 GRANADA ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1473
Practice Address - Country:US
Practice Address - Phone:913-703-7641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017017732235Z00000X
KS4250235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist