Healthcare Provider Details

I. General information

NPI: 1841914157
Provider Name (Legal Business Name): RYAN THOMAS LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 40TH ST
OAKLAND CA
94609-2691
US

IV. Provider business mailing address

PO BOX 3321
OAKLAND CA
94609-0321
US

V. Phone/Fax

Practice location:
  • Phone: 510-224-5577
  • Fax:
Mailing address:
  • Phone: 510-214-2792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPSB94029781
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: