Provider Demographics
NPI:1972756500
Name:LEE, STACY KATHLEEN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:KATHLEEN
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 1:3705 HAVEN AVE # 119
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-1011
Mailing Address - Country:US
Mailing Address - Phone:650-308-9159
Mailing Address - Fax:
Practice Address - Street 1:3705 HAVEN AVE # 119
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-1011
Practice Address - Country:US
Practice Address - Phone:650-308-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80016106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist