Provider Demographics
NPI:1508303959
Name:MONTAGUE, KARLESIA TIARA (MS, LPCA, LCASA, NCC)
Entity Type:Individual
Prefix:MS
First Name:KARLESIA
Middle Name:TIARA
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:MS, LPCA, LCASA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 WINDWARD PSGE
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-9430
Mailing Address - Country:US
Mailing Address - Phone:919-819-2447
Mailing Address - Fax:
Practice Address - Street 1:3701 NASH ST NW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-1127
Practice Address - Country:US
Practice Address - Phone:252-674-1812
Practice Address - Fax:252-674-1849
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21522101YA0400X
NCA12394101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)