MEDICARE: ANDREA MARIE LEE PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PTH3542	AL
2	225100000X	Physical Therapist	21780	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51534040	OTHER	AL	BLUE CROSS BLUE SHEILD

General Provider Information

NPI Number	:	1427094689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA MARIE LEE PT

Provider Business Mailing Address
First Line	:	1422 SEMINOLE CIR
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91784-8043
Country	:	US
Telephone Number	:	205-862-1926
Fax Number	:

Provider Business Practice Location Address
First Line	:	1422 SEMINOLE CIR
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91784-8043
Country	:	US
Telephone Number	:	205-862-1926
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	11/09/2021

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