Provider Demographics
NPI:1154645059
Name:LEE, YI-SHAN (LAC)
Entity Type:Individual
Prefix:
First Name:YI-SHAN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:SHU YU
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:189 LEPRINO CIR
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561-1068
Mailing Address - Country:US
Mailing Address - Phone:951-691-6537
Mailing Address - Fax:415-352-5089
Practice Address - Street 1:459 23RD ST APT 207
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2307
Practice Address - Country:US
Practice Address - Phone:951-691-6537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13664101YA0400X
CA15994101YA0400X
171M00000X, 174400000X, 175T00000X
CAAC12729171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5587818740OtherRCFE RESIDENTIAL ELDERLY ADMINISTRATOR CERTIFICAAAAAAATAION