MEDICARE: SUSAN LEE MS, MDIV

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	101YM0800X	Mental Health Counselor	108115	CA

General Provider Information

NPI Number	:	1316762925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN LEE MS, MDIV

Provider Business Mailing Address
First Line	:	48 CIELO CRESTA
Second Line	:
City	:	MISSION VIEJO
State	:	CA
Zip	:	92692-7901
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	27285 LAS RAMBLAS STE 140
Second Line	:
City	:	MISSION VIEJO
State	:	CA
Zip	:	92691-8551
Country	:	US
Telephone Number	:	949-370-1778
Fax Number	:

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

Provider Enumeration Date	:	11/19/2024
Last Update Date	:	11/19/2024

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