Healthcare Provider Details

I. General information

NPI: 1881726735
Provider Name (Legal Business Name): LEE VALENTINE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14660 OXNARD ST
VAN NUYS CA
91411-3119
US

IV. Provider business mailing address

3332 ENCINAL AVE
LA CRESCENTA CA
91214-2506
US

V. Phone/Fax

Practice location:
  • Phone: 818-901-4836
  • Fax: 818-376-0044
Mailing address:
  • Phone: 818-512-1027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberA8388101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: