Provider Demographics
NPI:1043680804
Name:OBERG, LEE
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:OBERG
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 1:149 BENITO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2112
Mailing Address - Country:US
Mailing Address - Phone:831-278-0932
Mailing Address - Fax:
Practice Address - Street 1:8030 SOQUEL AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2096
Practice Address - Country:US
Practice Address - Phone:831-476-1124
Practice Address - Fax:831-476-1125
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-O131220103101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)