Provider Demographics
NPI:1174784144
Name:LEE, EMBER LYNN
Entity type:Individual
Prefix:
First Name:EMBER
Middle Name:LYNN
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4046 1ST AVE
Mailing Address - Street 2:#305
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2036
Mailing Address - Country:US
Mailing Address - Phone:334-707-0380
Mailing Address - Fax:
Practice Address - Street 1:3665 KEARNY VILLA RD
Practice Address - Street 2:#101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1953
Practice Address - Country:US
Practice Address - Phone:858-966-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-22
Last Update Date:2008-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-1691313OtherRADY CHILDREN'S HOSPITAL SAN DIEGO, OUTPATIENT PSYCHIATRY DEPARTMENT