Healthcare Provider Details

I. General information

NPI: 1437801107
Provider Name (Legal Business Name): MONTAYE KYLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CENTRE LAKE DR STE 100
ONTARIO CA
91761-1202
US

IV. Provider business mailing address

3401 CENTRE LAKE DR STE 100
ONTARIO CA
91761-1202
US

V. Phone/Fax

Practice location:
  • Phone: 909-323-7100
  • Fax: 909-323-2900
Mailing address:
  • Phone: 909-323-7100
  • Fax: 909-323-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number138894
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: