Provider Demographics
NPI:1316515133
Name:LEE, ANDY K
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:K
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 PINNACLE CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2432
Mailing Address - Country:US
Mailing Address - Phone:408-480-0052
Mailing Address - Fax:
Practice Address - Street 1:1215 OBRIEN DR
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-1412
Practice Address - Country:US
Practice Address - Phone:650-260-3805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD7444358106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician