Provider Demographics
NPI:1114207578
Name:LUKAS, CARLY (MFT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:LUKAS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 AILEEN ST UPPR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2708
Mailing Address - Country:US
Mailing Address - Phone:512-720-1115
Mailing Address - Fax:
Practice Address - Street 1:11175 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-2157
Practice Address - Country:US
Practice Address - Phone:510-559-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X
CA88544106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool