Provider Demographics
NPI:1750655759
Name:LEE, TIEASE (LCSW)
Entity Type:Individual
Prefix:
First Name:TIEASE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 N GOWER ST STE 204
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7598
Mailing Address - Country:US
Mailing Address - Phone:323-438-2977
Mailing Address - Fax:
Practice Address - Street 1:1601 N GOWER ST STE 204
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-7598
Practice Address - Country:US
Practice Address - Phone:323-438-2977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA822041041C0700X
CAASW613881041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL