Healthcare Provider Details

I. General information

NPI: 1548507775
Provider Name (Legal Business Name): DR JOHN Y LEE CLINICAL PSYCHOLOGIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16161 VENTURA BLVD 224
ENCINO CA
91436-2522
US

IV. Provider business mailing address

8349 AURA AVE
NORTHRIDGE CA
91324-4202
US

V. Phone/Fax

Practice location:
  • Phone: 818-631-8349
  • Fax:
Mailing address:
  • Phone: 818-631-8349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number25158
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number25158
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN Y LEE
Title or Position: CEO
Credential: PHD
Phone: 818-631-8349