Basic Information
| Provider Information | |||||||||
| NPI: | 1639624950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1266 14TH ST., LINCOLN FAMILIES | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102734700 | ||||||||
| FaxNumber: | 4156950829 | ||||||||
| Practice Location | |||||||||
| Address1: | 1266 14TH ST., LINCOLN FAMILIES | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102734700 | ||||||||
| FaxNumber: | 4156950829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2016 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor |
No ID Information.