Healthcare Provider Details

I. General information

NPI: 1336085760
Provider Name (Legal Business Name): RYAN C LEE LGPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 CARROLL PKWY APT 8A
FREDERICK MD
21701-4061
US

IV. Provider business mailing address

750 CARROLL PKWY APT 8A
FREDERICK MD
21701-4061
US

V. Phone/Fax

Practice location:
  • Phone: 510-520-8919
  • Fax:
Mailing address:
  • Phone: 510-520-8919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: