Provider Demographics
NPI:1548153596
Name:MONTGOMERY, ADAM THOMAS (COTA/L)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:THOMAS
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15487 WILD CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:EMINENCE
Mailing Address - State:MO
Mailing Address - Zip Code:65588-9137
Mailing Address - Country:US
Mailing Address - Phone:573-351-9660
Mailing Address - Fax:
Practice Address - Street 1:15487 WILD CHERRY LN
Practice Address - Street 2:
Practice Address - City:EMINENCE
Practice Address - State:MO
Practice Address - Zip Code:65588-9137
Practice Address - Country:US
Practice Address - Phone:573-351-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022046153224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant