Provider Demographics
NPI:1114322815
Name:LEE, MANDY
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MANDY
Other - Middle Name:LEE
Other - Last Name:RICHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:818 MARQUETTE DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-7399
Mailing Address - Country:US
Mailing Address - Phone:712-299-3532
Mailing Address - Fax:
Practice Address - Street 1:45 TRIFECTA PL.
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-4901
Practice Address - Country:US
Practice Address - Phone:304-725-4536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst