Healthcare Provider Details

I. General information

NPI: 1700075017
Provider Name (Legal Business Name): SIEUN LEE MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GRAND AVE
PALISADES PARK NJ
07650-1076
US

IV. Provider business mailing address

21 GRAND AVE
PALISADES PARK NJ
07650-1076
US

V. Phone/Fax

Practice location:
  • Phone: 201-313-4840
  • Fax: 201-313-9353
Mailing address:
  • Phone: 201-313-4840
  • Fax: 201-313-9353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01132500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: