Provider Demographics
NPI:1649762089
Name:LEE, KO EUN
Entity type:Individual
Prefix:
First Name:KO EUN
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 1:5743 NORDEEN OAK CT
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2209
Mailing Address - Country:US
Mailing Address - Phone:703-508-1074
Mailing Address - Fax:
Practice Address - Street 1:8519 TUTTLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1508
Practice Address - Country:US
Practice Address - Phone:703-451-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0733008393101YS0200X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician