Provider Demographics
NPI:1053027961
Name:LEBACQZ, KRISTEN (MFT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:LEBACQZ
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 1:2400 LAS GALLINAS AVE STE 265B
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1453
Mailing Address - Country:US
Mailing Address - Phone:415-729-4802
Mailing Address - Fax:
Practice Address - Street 1:2400 LAS GALLINAS AVE STE 265B
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1453
Practice Address - Country:US
Practice Address - Phone:415-729-4802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89999106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist