Provider Demographics
NPI:1043753445
Name:LEBARD, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:LEBARD
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 1:1616 CORNWALL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4648
Mailing Address - Country:US
Mailing Address - Phone:425-273-0129
Mailing Address - Fax:
Practice Address - Street 1:1616 CORNWALL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4648
Practice Address - Country:US
Practice Address - Phone:425-273-0129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60715119Medicaid