Provider Demographics
NPI:1922690726
Name:LEE, STEPHANIE DIANE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANE
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 1:7969 MADISON AVE APT 708
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-7822
Mailing Address - Country:US
Mailing Address - Phone:916-759-7854
Mailing Address - Fax:
Practice Address - Street 1:7969 MADISON AVE APT 708
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-7822
Practice Address - Country:US
Practice Address - Phone:916-759-7854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty