Provider Demographics
NPI:1295880961
Name:LEE, KEVIN E (MFT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:E
Last Name:LEE
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 S AUGUSTA PL
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-5772
Mailing Address - Country:US
Mailing Address - Phone:909-868-0300
Mailing Address - Fax:909-947-9598
Practice Address - Street 1:375 S MAIN ST STE 107
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-1639
Practice Address - Country:US
Practice Address - Phone:909-868-0300
Practice Address - Fax:909-947-9598
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMF169650106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMF1696500Medicaid