=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356480305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GENIE LEE LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 12/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4990 SPEAK LN
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95118-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-499-1762
-----------------------------------------------------
Fax | 408-792-2158
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4990 SPEAK LN
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95118-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-499-1762
-----------------------------------------------------
Fax | 408-792-2158
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC 37440
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------