Provider Demographics
NPI:1801348107
Name:MONTENEGRO, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MONTENEGRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-4326
Mailing Address - Country:US
Mailing Address - Phone:360-675-5425
Mailing Address - Fax:
Practice Address - Street 1:231 SE BARRINGTON DRIVE
Practice Address - Street 2:SUITE 203
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277
Practice Address - Country:US
Practice Address - Phone:360-240-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1093009193103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst