Provider Demographics
NPI:1376576645
Name:KIBBLE, LENA (MFT)
Entity type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:KIBBLE
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 1:6647 MEADOW PINES DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928
Mailing Address - Country:US
Mailing Address - Phone:707-584-1594
Mailing Address - Fax:707-588-9469
Practice Address - Street 1:3069 SOLANO AVE
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-4510
Practice Address - Country:US
Practice Address - Phone:707-253-0535
Practice Address - Fax:707-588-9469
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC-24252101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC-24252OtherMARRIAGE THERAPIST