Healthcare Provider Details

I. General information

NPI: 1457108474
Provider Name (Legal Business Name): CAROLINE LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 VAN NUYS BLVD STE 201
SHERMAN OAKS CA
91403-1700
US

IV. Provider business mailing address

4940 VAN NUYS BLVD STE 201
SHERMAN OAKS CA
91403-1700
US

V. Phone/Fax

Practice location:
  • Phone: 818-985-0560
  • Fax: 818-985-7193
Mailing address:
  • Phone: 818-985-0560
  • Fax: 818-985-7193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-EGNDRU
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: