Healthcare Provider Details

I. General information

NPI: 1790519114
Provider Name (Legal Business Name): CAROLE FELICIA LEE OT; IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3309 WOOD TER
LOS ANGELES CA
90027-2204
US

IV. Provider business mailing address

3309 WOOD TER
LOS ANGELES CA
90027-2204
US

V. Phone/Fax

Practice location:
  • Phone: 323-528-1406
  • Fax:
Mailing address:
  • Phone: 323-528-1406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number5627
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-152875
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: