Provider Demographics
NPI:1730607144
Name:LEE, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
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 1:18525 SUTTER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-2899
Mailing Address - Country:US
Mailing Address - Phone:408-762-7022
Mailing Address - Fax:
Practice Address - Street 1:4612 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-4520
Practice Address - Country:US
Practice Address - Phone:916-379-5876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X, 390200000X
CA111330106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1730607144Medicaid