Provider Demographics
NPI:1407461189
Name:YOUR PEDIATRIC PSYCHOLOGIST, LLC
Entity Type:Organization
Organization Name:YOUR PEDIATRIC PSYCHOLOGIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC HEALTH PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JINSOON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, MSCP, BCB
Authorized Official - Phone:720-515-2535
Mailing Address - Street 1:6140 S GUN CLUB RD # K6-353
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-5306
Mailing Address - Country:US
Mailing Address - Phone:310-876-4419
Mailing Address - Fax:
Practice Address - Street 1:1700 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1668
Practice Address - Country:US
Practice Address - Phone:720-515-2535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-10
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty