Provider Demographics
NPI:1639611387
Name:LEE, MIJA
Entity type:Individual
Prefix:MRS
First Name:MIJA
Middle Name:
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 1:2271 W MALVERN AVE # 100
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-2106
Mailing Address - Country:US
Mailing Address - Phone:330-861-2317
Mailing Address - Fax:
Practice Address - Street 1:1401 W VALENCIA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-2106
Practice Address - Country:US
Practice Address - Phone:330-861-2317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-11
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALPCC14124OtherBBS
M63715739OtherPASSPORT-KOREA