Healthcare Provider Details

I. General information

NPI: 1487805545
Provider Name (Legal Business Name): LEE STILLERMAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UCR COUNSELING CTR VEITCH STUDENT CENTER, NORTH WING
RIVERSIDE CA
92521-0001
US

IV. Provider business mailing address

17100 ROCKY BEND CT
RIVERSIDE CA
92503-0246
US

V. Phone/Fax

Practice location:
  • Phone: 562-208-1056
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number21971
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: