Provider Demographics
NPI:1538477039
Name:HACKNEY, KELLY (MA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HACKNEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 AINSWORTH LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-3233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:503 HEATHMORE CT
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-3286
Practice Address - Country:US
Practice Address - Phone:707-799-5486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA79657106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist