Provider Demographics
NPI:1629969431
Name:LEE, ELLY MINA
Entity type:Individual
Prefix:
First Name:ELLY
Middle Name:MINA
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WEI
Other - Middle Name:
Other - Last Name:ZOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:617 W SMOKE TREE RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-6830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:617 W SMOKE TREE RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-6830
Practice Address - Country:US
Practice Address - Phone:602-525-7358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-10
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician