Provider Demographics
NPI:1083003214
Name:LEE, MICHELLE (PTA)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3051 W CHERYLLYN LN # 35
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3168
Mailing Address - Country:US
Mailing Address - Phone:714-371-8796
Mailing Address - Fax:
Practice Address - Street 1:3051 W CHERYLLYN LN # 35
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3168
Practice Address - Country:US
Practice Address - Phone:714-371-8796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9196225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant