Provider Demographics
NPI:1821605627
Name:LEE, MICHELLE MINKYUNG
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MINKYUNG
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 NEWBURY WAY
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4625
Mailing Address - Country:US
Mailing Address - Phone:909-518-1968
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLAZA DRIVEWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3924
Practice Address - Country:US
Practice Address - Phone:310-267-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14874Medicaid