Provider Demographics
NPI:1245428945
Name:LEE, THEODORE TAEWOO (LCSW)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:TAEWOO
Last Name:LEE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 GREAT OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1310
Mailing Address - Country:US
Mailing Address - Phone:408-363-3000
Mailing Address - Fax:408-363-3406
Practice Address - Street 1:80 GREAT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1310
Practice Address - Country:US
Practice Address - Phone:408-363-3000
Practice Address - Fax:408-363-3406
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA272741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical