MEDICARE: GRACE MIMI LEE LCSW

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	1041C0700X	Clinical Social Worker	ASW 16334	CA
2	1041C0700X	Clinical Social Worker	LCS 28912	CA
3	1041C0700X	Clinical Social Worker	ASW 27425	CA

General Provider Information

NPI Number	:	1609968932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE MIMI LEE LCSW

Provider Business Mailing Address
First Line	:	405 W 5TH ST
Second Line	:	SUITE #212
City	:	SANTA ANA
State	:	CA
Zip	:	92701-4599
Country	:	US
Telephone Number	:	714-834-2125
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 W 5TH ST
Second Line	:	SUITE #212
City	:	SANTA ANA
State	:	CA
Zip	:	92701-4599
Country	:	US
Telephone Number	:	714-834-2125
Fax Number	:

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

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	04/01/2014

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