Basic Information
| Provider Information | |||||||||
| NPI: | 1003026543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11951 HESPERIA RD | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923451855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609562345 | ||||||||
| FaxNumber: | 7609563761 | ||||||||
| Practice Location | |||||||||
| Address1: | 11951 HESPERIA RD | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923451855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609562345 | ||||||||
| FaxNumber: | 7609563761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PT28096 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.