Provider Demographics
NPI:1104378371
Name:LEE, BLIA
Entity Type:Individual
Prefix:
First Name:BLIA
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 1:1875 S GENEVA RD
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-2217
Mailing Address - Country:US
Mailing Address - Phone:801-456-9954
Mailing Address - Fax:801-456-9954
Practice Address - Street 1:1875 S GENEVA RD
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-2217
Practice Address - Country:US
Practice Address - Phone:801-456-9954
Practice Address - Fax:801-456-9954
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-16-23491106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician