Provider Demographics
NPI:1831696335
Name:LEE, YENJU (PHD)
Entity type:Individual
Prefix:
First Name:YENJU
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:G3230 BEECHER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3604
Mailing Address - Country:US
Mailing Address - Phone:810-342-5656
Mailing Address - Fax:
Practice Address - Street 1:G3230 BEECHER RD STE 1
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3604
Practice Address - Country:US
Practice Address - Phone:810-342-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI6301018725103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program