Provider Demographics
NPI:1003472184
Name:LEE, EDWIN BRYCE (DPT)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:BRYCE
Last Name:LEE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 LASALLE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23509-1122
Mailing Address - Country:US
Mailing Address - Phone:757-227-7600
Mailing Address - Fax:
Practice Address - Street 1:1512 TECHNOLOGY DR STE 102
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5979
Practice Address - Country:US
Practice Address - Phone:757-227-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist