Provider Demographics
NPI:1114448065
Name:LEE, MARY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21924 W HIGHWAY 62
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:AR
Mailing Address - Zip Code:72744-9554
Mailing Address - Country:US
Mailing Address - Phone:479-463-0263
Mailing Address - Fax:
Practice Address - Street 1:1276 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CAVE SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72718
Practice Address - Country:US
Practice Address - Phone:479-245-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR228589721Medicaid