Provider Demographics
NPI:1033540356
Name:LEE, CORDELLERO DASHUN
Entity Type:Individual
Prefix:
First Name:CORDELLERO
Middle Name:DASHUN
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 GUERNEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7220
Mailing Address - Country:US
Mailing Address - Phone:707-516-7700
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT VINCENTS DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1504
Practice Address - Country:US
Practice Address - Phone:415-507-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health