Healthcare Provider Details

I. General information

NPI: 1235601725
Provider Name (Legal Business Name): SARAH LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2018
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6949 DEW POINT WAY
FONTANA CA
92336-1865
US

IV. Provider business mailing address

6949 DEW POINT WAY
FONTANA CA
92336-1865
US

V. Phone/Fax

Practice location:
  • Phone: 909-317-8499
  • Fax:
Mailing address:
  • Phone: 909-317-8499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-47694
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number00002502
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: