Healthcare Provider Details

I. General information

NPI: 1902974827
Provider Name (Legal Business Name): KYUNG SHIN LEE LCSW, BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 E. 1ST. ST. STE. 100
SANTA ANA CA
92701
US

IV. Provider business mailing address

18 ASPEN TREE LANE
IRVINE CA
92612
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • Fax:
Mailing address:
  • Phone: 949-786-6067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLZ12728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: