Provider Demographics
NPI:1649413758
Name:LEE, CALEB DAEKYU (LAC,OMD, PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:CALEB
Middle Name:DAEKYU
Last Name:LEE
Suffix:
Gender:
Credentials:LAC,OMD, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9861 BROKEN LAND PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-3031
Mailing Address - Country:US
Mailing Address - Phone:410-213-5233
Mailing Address - Fax:410-213-5233
Practice Address - Street 1:9861 BROKEN LAND PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-3031
Practice Address - Country:US
Practice Address - Phone:410-213-5233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01817171100000X
MDR253173363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No171100000XOther Service ProvidersAcupuncturist