Provider Demographics
NPI:1093596041
Name:LEE, SORIM
Entity Type:Individual
Prefix:
First Name:SORIM
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 N PINE ST STE N
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-2830
Mailing Address - Country:US
Mailing Address - Phone:337-226-5007
Mailing Address - Fax:
Practice Address - Street 1:1118 N PINE ST STE N
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-2830
Practice Address - Country:US
Practice Address - Phone:337-226-5007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA9445225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist