Healthcare Provider Details

I. General information

NPI: 1639844426
Provider Name (Legal Business Name): ELIZABETH LEE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 08/12/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5857 ROHN WAY
SAN JOSE CA
95123-3526
US

IV. Provider business mailing address

5857 ROHN WAY
SAN JOSE CA
95123-3526
US

V. Phone/Fax

Practice location:
  • Phone: 408-981-5371
  • Fax:
Mailing address:
  • Phone: 408-981-5371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLEP4123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: