Provider Demographics
NPI:1841772407
Name:LEE, SHANNON (PT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 E LAMBERT RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-4370
Mailing Address - Country:US
Mailing Address - Phone:714-988-8110
Mailing Address - Fax:714-988-8111
Practice Address - Street 1:13931 CARROLL WAY STE B
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1861
Practice Address - Country:US
Practice Address - Phone:714-988-8120
Practice Address - Fax:714-988-8119
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294824225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist