Provider Demographics
NPI:1043365323
Name:LEE, BRIAN W (DPT, OCS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:W
Last Name:LEE
Suffix:
Gender:M
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4815
Mailing Address - Country:US
Mailing Address - Phone:208-454-0505
Mailing Address - Fax:208-454-0559
Practice Address - Street 1:206 E ELM ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4815
Practice Address - Country:US
Practice Address - Phone:208-454-0505
Practice Address - Fax:208-454-0559
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1654192Medicare ID - Type Unspecified