Provider Demographics
NPI:1821707845
Name:MONTGOMERY, KARLI SHAYE
Entity Type:Individual
Prefix:
First Name:KARLI
Middle Name:SHAYE
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 1:2067 PALOLO AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-6189
Mailing Address - Country:US
Mailing Address - Phone:480-620-9517
Mailing Address - Fax:
Practice Address - Street 1:94-450 MOKUOLA ST STE 100
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3388
Practice Address - Country:US
Practice Address - Phone:480-620-9517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
HIBACB610465106S00000X
HIRBT-20-143505106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician