Provider Demographics
NPI:1003553728
Name:MONTENEGRO, KERY
Entity Type:Individual
Prefix:
First Name:KERY
Middle Name:
Last Name:MONTENEGRO
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 1:19177 NW 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-2104
Mailing Address - Country:US
Mailing Address - Phone:786-270-6823
Mailing Address - Fax:
Practice Address - Street 1:19177 NW 45TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-2104
Practice Address - Country:US
Practice Address - Phone:786-270-6823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-14
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-210087106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM-535-503-74-906-0OtherDRIVER LICENCE