Provider Demographics
NPI:1992014047
Name:LEE, CARL
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:
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 1:802 W COLTON AVE STE C
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2905
Mailing Address - Country:US
Mailing Address - Phone:909-335-2989
Mailing Address - Fax:
Practice Address - Street 1:802 W COLTON AVE STE C
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2905
Practice Address - Country:US
Practice Address - Phone:909-335-2989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARS6083101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)