Provider Demographics
NPI:1003963638
Name:LEE, GARY W (LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:LEE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1965 S EAGLE RD
Mailing Address - Street 2:STE 140
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9288
Mailing Address - Country:US
Mailing Address - Phone:208-957-6514
Mailing Address - Fax:208-957-6506
Practice Address - Street 1:1965 S EAGLE RD
Practice Address - Street 2:STE 140
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9288
Practice Address - Country:US
Practice Address - Phone:208-957-6514
Practice Address - Fax:208-957-6506
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW5781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010015750OtherREGENCE BLUE SHIELD OF ID
IDL9982OtherBLUE CROSS OF IDAHO
NY077063OtherVALUE OPTIONS