Provider Demographics
NPI:1255843793
Name:LEE, SANDRA SUNGMI (COTA/L)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:SUNGMI
Last Name:LEE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 S ZEKE AND ELSIE AVE
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-6370
Mailing Address - Country:US
Mailing Address - Phone:562-480-4282
Mailing Address - Fax:
Practice Address - Street 1:500 W CENTRAL AVE STE B
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3036
Practice Address - Country:US
Practice Address - Phone:714-529-5022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4158224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant