Provider Demographics
NPI:1003230657
Name:LEE, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
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 1:12086 FORT CAROLINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-2687
Mailing Address - Country:US
Mailing Address - Phone:904-565-1271
Mailing Address - Fax:904-645-7325
Practice Address - Street 1:12086 FT.CAROLINE RD SUITE 401
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-1536
Practice Address - Country:US
Practice Address - Phone:904-565-1271
Practice Address - Fax:904-645-7325
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW23231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW2323OtherSTATE LICENSE