Provider Demographics
NPI:1023202884
Name:LAKHARDT, KELLYN ASHTON
Entity Type:Individual
Prefix:
First Name:KELLYN
Middle Name:ASHTON
Last Name:LAKHARDT
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 1:584 CASTRO ST
Mailing Address - Street 2:107
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2512
Mailing Address - Country:US
Mailing Address - Phone:415-948-7472
Mailing Address - Fax:
Practice Address - Street 1:584 CASTRO ST
Practice Address - Street 2:107
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-2512
Practice Address - Country:US
Practice Address - Phone:415-948-7472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA50233106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor