Provider Demographics
NPI:1003905704
Name:LEE, DAVID C (PHD, JD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:C
Last Name:LEE
Suffix:
Gender:M
Credentials:PHD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 CAMELOT DR
Mailing Address - Street 2:UNIT 412
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-1005
Mailing Address - Country:US
Mailing Address - Phone:608-334-3309
Mailing Address - Fax:608-301-1390
Practice Address - Street 1:1713 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-1005
Practice Address - Country:US
Practice Address - Phone:608-301-1047
Practice Address - Fax:608-301-1390
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2407-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIMM176Medicare ID - Type Unspecified