Provider Demographics
NPI:1184296964
Name:LEE, DIEDRA (AMFT)
Entity type:Individual
Prefix:
First Name:DIEDRA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 151112
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92175-1112
Mailing Address - Country:US
Mailing Address - Phone:619-895-7993
Mailing Address - Fax:
Practice Address - Street 1:1061 S 41ST ST APT 6
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-3379
Practice Address - Country:US
Practice Address - Phone:619-316-9301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110576101YM0800X, 106H00000X, 106H00000X
103T00000X
CA103TC1900X, 103TS0200X, 251B00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No251B00000XAgenciesCase Management
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program