Basic Information
| Provider Information | |||||||||
| NPI: | 1992007785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 934 E CHOCOLATE AVE | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170331215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176652675 | ||||||||
| FaxNumber: | 7172560599 | ||||||||
| Practice Location | |||||||||
| Address1: | 24511 W JAYNE AVE | ||||||||
| Address2: | COALINGA STATE HOSPITAL | ||||||||
| City: | COALINGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932109503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599354300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2010 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PS019334 | PA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.