Provider Demographics
NPI:1093950727
Name:KING, LEE GAIL (MED)
Entity Type:Individual
Prefix:MS
First Name:LEE
Middle Name:GAIL
Last Name:KING
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 COMMONWEALTH AVE
Mailing Address - Street 2:3
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5145
Mailing Address - Country:US
Mailing Address - Phone:617-782-0452
Mailing Address - Fax:
Practice Address - Street 1:61 MEDFORD ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3421
Practice Address - Country:US
Practice Address - Phone:617-629-3919
Practice Address - Fax:617-629-4644
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206691104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker