Provider Demographics
NPI:1902974827
Name:LEE, KYUNG SHIN (LCSW, BCD)
Entity Type:Individual
Prefix:
First Name:KYUNG
Middle Name:SHIN
Last Name:LEE
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ASPEN TREE LANE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612
Mailing Address - Country:US
Mailing Address - Phone:949-786-6067
Mailing Address - Fax:
Practice Address - Street 1:1440 E. 1ST. ST.
Practice Address - Street 2:STE. 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701
Practice Address - Country:US
Practice Address - Phone:714-953-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALZ127281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical