Basic Information
| Provider Information | |||||||||
| NPI: | 1639605959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | CHERTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 N R ST | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936374465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596620527 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5610 W DONNER AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937223721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592812562 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2017 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 10604-R | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | ACSW89376 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.