Provider Demographics
NPI:1083838056
Name:LEE, EVELYN FONG (PT)
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:FONG
Last Name:LEE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 BELL RUSSELL WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-4243
Mailing Address - Country:US
Mailing Address - Phone:916-393-6711
Mailing Address - Fax:
Practice Address - Street 1:771 BELL RUSSELL WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-4243
Practice Address - Country:US
Practice Address - Phone:916-393-6711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 6963225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMS200082OtherCHILDREN MEDICAL SERVICES
CAPT6963OtherP.T. LICENSE