Provider Demographics
NPI:1932518511
Name:LEE, SHANNEN BOYOUNG
Entity Type:Individual
Prefix:
First Name:SHANNEN
Middle Name:BOYOUNG
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 1:11218 CAMARILLO ST APT 304
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-1243
Mailing Address - Country:US
Mailing Address - Phone:213-928-7606
Mailing Address - Fax:
Practice Address - Street 1:11218 CAMARILLO ST APT 304
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-1243
Practice Address - Country:US
Practice Address - Phone:213-928-7606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical