Provider Demographics
NPI:1053732776
Name:MONTGOMERY, KYLE ADRIAN (MS, ATC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ADRIAN
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2761 SEA PINES CIR E
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-3008
Mailing Address - Country:US
Mailing Address - Phone:727-515-0214
Mailing Address - Fax:
Practice Address - Street 1:2761 SEA PINES CIR E
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3008
Practice Address - Country:US
Practice Address - Phone:727-515-0214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL35942255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer