Provider Demographics
NPI:1326188962
Name:LEE, KEALAILANI
Entity Type:Individual
Prefix:
First Name:KEALAILANI
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 WALKER DR
Mailing Address - Street 2:APT. #5
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-3679
Mailing Address - Country:US
Mailing Address - Phone:408-744-1776
Mailing Address - Fax:
Practice Address - Street 1:2 EDGEWOOD CT
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94014-1841
Practice Address - Country:US
Practice Address - Phone:650-994-7110
Practice Address - Fax:650-994-7180
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00148919101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00148919OtherMFT INTERN