Basic Information
| Provider Information | |||||||||
| NPI: | 1528072600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MOON | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38 RADIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103094212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189679145 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1745 BROADWAY | ||||||||
| Address2: | 17 FL | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100194640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518102 | ||||||||
| FaxNumber: | 2125370102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 06/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 7336 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 01879854 | 05 | NY | MEDICAID |