Basic Information
| Provider Information | |||||||||
| NPI: | 1154832640 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | SU JIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1603 W CATALPA DR APT B | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928014172 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4909 MURPHY CANYON RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007876787 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2017 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 114189 | TX | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 33224 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.