Provider Demographics
NPI:1073663415
Name:LEE, SUSAN D (COTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:LEE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:D
Other - Last Name:DEGRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:11 NORTH MAIN STREET
Mailing Address - City:GWINNER
Mailing Address - State:ND
Mailing Address - Zip Code:58040-0586
Mailing Address - Country:US
Mailing Address - Phone:701-678-2244
Mailing Address - Fax:701-678-2210
Practice Address - Street 1:11 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:GWINNER
Practice Address - State:ND
Practice Address - Zip Code:58040-0586
Practice Address - Country:US
Practice Address - Phone:701-678-2244
Practice Address - Fax:701-678-2210
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND587224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant