Provider Demographics
NPI:1568192953
Name:LEE, ELLA ROSE NMN (RADT)
Entity Type:Individual
Prefix:
First Name:ELLA ROSE
Middle Name:NMN
Last Name:LEE
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3594 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4989
Mailing Address - Country:US
Mailing Address - Phone:619-296-1151
Mailing Address - Fax:619-296-6218
Practice Address - Street 1:3594 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4989
Practice Address - Country:US
Practice Address - Phone:619-296-1151
Practice Address - Fax:619-296-6218
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1465840422175T00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist