Provider Demographics
NPI:1083707277
Name:LEE, MICHAEL S (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
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 1:2007 S PLAZA
Mailing Address - Street 2:SUITE #1
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617
Mailing Address - Country:US
Mailing Address - Phone:208-365-5445
Mailing Address - Fax:208-365-6226
Practice Address - Street 1:2007 S PLAZA
Practice Address - Street 2:SUITE #1
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617
Practice Address - Country:US
Practice Address - Phone:208-365-5445
Practice Address - Fax:208-365-6226
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW242101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1693579Medicare ID - Type Unspecified