Provider Demographics
NPI:1770950198
Name:LEE, IRENE SONG (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:SONG
Last Name:LEE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5333 KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-1734
Mailing Address - Country:US
Mailing Address - Phone:626-532-5256
Mailing Address - Fax:
Practice Address - Street 1:1411 W 190TH ST STE 110
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4370
Practice Address - Country:US
Practice Address - Phone:213-863-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15729225X00000X
CAOT 15729225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist