Healthcare Provider Details

I. General information

NPI: 1902465164
Provider Name (Legal Business Name): SEOYOUNG LEE MA, CF-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALICE LEE

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 PIERCY RD
SAN JOSE CA
95138-1403
US

IV. Provider business mailing address

130 COLLEGE AVE NE APT 3
GRAND RAPIDS MI
49503-3420
US

V. Phone/Fax

Practice location:
  • Phone: 408-692-5197
  • Fax:
Mailing address:
  • Phone: 616-264-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: