Provider Demographics
NPI:1104187723
Name:LEE, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
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 1:355 N MILL ST
Mailing Address - Street 2:APT 311
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-1556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 N MILL ST
Practice Address - Street 2:APT 311
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-1556
Practice Address - Country:US
Practice Address - Phone:310-927-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3413222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3413OtherCOLORADO