Provider Demographics
NPI:1063297430
Name:MONTGOMERY, GRACE MALLIS
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:MALLIS
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 1:12831 TIKAL WAY
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-7253
Mailing Address - Country:US
Mailing Address - Phone:727-386-3896
Mailing Address - Fax:
Practice Address - Street 1:4707 W GANDY BLVD STE 3
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-3310
Practice Address - Country:US
Practice Address - Phone:813-728-6601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist