Basic Information
| Provider Information | |||||||||
| NPI: | 1568938694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAKE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11951 HESPERIA RD | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923451855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609562345 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11951 HESPERIA RD | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923451855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609592345 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2018 | ||||||||
| LastUpdateDate: | 10/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 109558 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 109558 | 01 | CA | MFT REGISTERED INTERN | OTHER | 109558 | 01 | CA | BBS | OTHER |