Basic Information
Provider Information | |||||||||
NPI: | 1699435701 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEE | ||||||||
FirstName: | LUTHER | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18726 S WESTERN AVE | ||||||||
Address2: |   | ||||||||
City: | GARDENA | ||||||||
State: | CA | ||||||||
PostalCode: | 902483813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3108560800 | ||||||||
FaxNumber: | 8555682494 | ||||||||
Practice Location | |||||||||
Address1: | 8300 FM 1960 RD W | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770705654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8889222843 | ||||||||
FaxNumber: | 8555682494 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2021 | ||||||||
LastUpdateDate: | 01/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X |   | TX | N |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   | 106S00000X |   | TX | Y |   |   |   |   |
No ID Information.