Provider Demographics
NPI:1174415749
Name:LEE, HEE TAE
Entity type:Individual
Prefix:
First Name:HEE TAE
Middle Name:
Last Name:LEE
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 1:2466 MONTROSE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1476
Mailing Address - Country:US
Mailing Address - Phone:213-703-5526
Mailing Address - Fax:
Practice Address - Street 1:3030 W OLYMPIC BLVD STE 217
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6507
Practice Address - Country:US
Practice Address - Phone:213-703-5526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-17
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95037221363LP0808X
CA95231436163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse