Provider Demographics
NPI:1083164172
Name:LEE, ERICA (MA)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 BOATMAN AVE NW
Mailing Address - Street 2:
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360-7404
Mailing Address - Country:US
Mailing Address - Phone:253-392-7412
Mailing Address - Fax:
Practice Address - Street 1:1018 BOATMAN AVE NW
Practice Address - Street 2:
Practice Address - City:ORTING
Practice Address - State:WA
Practice Address - Zip Code:98360-7404
Practice Address - Country:US
Practice Address - Phone:253-392-7412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARBT-16-24155106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician