Provider Demographics
NPI:1255008421
Name:LEE, DERRIC JUSTIN (DPT)
Entity Type:Individual
Prefix:
First Name:DERRIC
Middle Name:JUSTIN
Last Name:LEE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 STEUBEN BAY
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502-6406
Mailing Address - Country:US
Mailing Address - Phone:510-846-8409
Mailing Address - Fax:
Practice Address - Street 1:2030 ADDISON ST STE 101
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1140
Practice Address - Country:US
Practice Address - Phone:510-644-8031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT300515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist