Provider Demographics
NPI:1629663489
Name:LEE, ILENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 A WALNUT ST.
Mailing Address - Street 2:STE 289
Mailing Address - City:BERKELY
Mailing Address - State:CA
Mailing Address - Zip Code:94709
Mailing Address - Country:US
Mailing Address - Phone:510-684-7025
Mailing Address - Fax:
Practice Address - Street 1:2915 FOREST AVE
Practice Address - Street 2:
Practice Address - City:BERKELY
Practice Address - State:CA
Practice Address - Zip Code:94705
Practice Address - Country:US
Practice Address - Phone:415-724-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health