MEDICARE: HYUN KYUNG LEE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY26279	CA
2	103TC0700X	Clinical Psychologist	PSY26279	CA

General Provider Information

NPI Number	:	1114375672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HYUN KYUNG LEE PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 642707
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-8234
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1840 S ELENA AVE STE 207
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5717
Country	:	US
Telephone Number	:	424-254-8182
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2016
Last Update Date	:	01/23/2017

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