Basic Information
| Provider Information | |||||||||
| NPI: | 1780153585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | SOO | ||||||||
| MiddleName: | JEONG | ||||||||
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| Credential: | RADT- I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18646 OXNARD ST | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913561486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189961051 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18646 OXNARD ST | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913561486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189961051 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2018 | ||||||||
| LastUpdateDate: | 11/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.