Provider Demographics
NPI:1033740154
Name:LEE, KRISTEN MASAE ALFONSO (CMT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MASAE ALFONSO
Last Name:LEE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5033
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-8001
Mailing Address - Country:US
Mailing Address - Phone:310-938-7100
Mailing Address - Fax:
Practice Address - Street 1:11498 PIERCE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3357
Practice Address - Country:US
Practice Address - Phone:951-354-6294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1821225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty