Provider Demographics
NPI:1659481711
Name:LEE, CHARLTON ROBERT
Entity Type:Individual
Prefix:
First Name:CHARLTON
Middle Name:ROBERT
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9680 APAWAMIS RD
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-1113
Mailing Address - Country:US
Mailing Address - Phone:760-329-1326
Mailing Address - Fax:760-329-4032
Practice Address - Street 1:17400 BUBBLING WELLS RD
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92241-7051
Practice Address - Country:US
Practice Address - Phone:760-251-2416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MFT184101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01802504Medicaid
CA33BE46OtherRIVERSIDE COUNTY