Basic Information
| Provider Information | |||||||||
| NPI: | 1104056902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | |||||||||
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| Credential: | SUDCC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 218 E COMMONWEALTH AVE | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928321911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149924770 | ||||||||
| FaxNumber: | 7149925475 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927054007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145423581 | ||||||||
| FaxNumber: | 7145422246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11603 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.