Provider Demographics
NPI:1124548904
Name:MONTIERTH, KAYLENE MARIE
Entity type:Individual
Prefix:
First Name:KAYLENE
Middle Name:MARIE
Last Name:MONTIERTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAYLENE
Other - Middle Name:MARIE
Other - Last Name:IDSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4100 S LINDSAY RD STE 113
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-1507
Mailing Address - Country:US
Mailing Address - Phone:480-219-3953
Mailing Address - Fax:
Practice Address - Street 1:4100 S LINDSAY RD STE 113
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-1507
Practice Address - Country:US
Practice Address - Phone:480-219-3953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA105672355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant