Provider Demographics
NPI:1215447628
Name:CONNECTED LIVES PSYCHOLOGICAL CORP.
Entity type:Organization
Organization Name:CONNECTED LIVES PSYCHOLOGICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:416-846-7547
Mailing Address - Street 1:1628 ALEMANY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94112-2610
Mailing Address - Country:US
Mailing Address - Phone:415-846-7547
Mailing Address - Fax:
Practice Address - Street 1:78 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94112-2549
Practice Address - Country:US
Practice Address - Phone:415-846-7547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27801103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty