Healthcare Provider Details

I. General information

NPI: 1568913374
Provider Name (Legal Business Name): NARAE LEE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 OAK ST APT D
SOUTH PASADENA CA
91030-4456
US

IV. Provider business mailing address

1420 OAK ST APT D
SOUTH PASADENA CA
91030-4456
US

V. Phone/Fax

Practice location:
  • Phone: 718-662-6401
  • Fax:
Mailing address:
  • Phone: 718-662-6401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number31314
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: