Provider Demographics
NPI:1336567023
Name:LEE, JUSTIN (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 W REDONDO BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3241
Mailing Address - Country:US
Mailing Address - Phone:714-590-3211
Mailing Address - Fax:714-590-3210
Practice Address - Street 1:1607 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3241
Practice Address - Country:US
Practice Address - Phone:714-590-3211
Practice Address - Fax:714-590-3210
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 41176225100000X
NY037122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist