=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104412139
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEWON LEE DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2020
-----------------------------------------------------
Last Update Date | 08/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15630 OLD COLUMBIA PIKE STE F
-----------------------------------------------------
City | BURTONSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20866-1617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-559-5270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 BUTTERFIELD RD STE 1600
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-1211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-370-8206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070-025543
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 30487
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------