Provider Demographics
NPI:1124215777
Name:LEE, NICHOLAS ALEXANDER (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALEXANDER
Last Name:LEE
Suffix:
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1676
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47308-1676
Mailing Address - Country:US
Mailing Address - Phone:765-286-7000
Mailing Address - Fax:765-213-2769
Practice Address - Street 1:333 S MADISON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47305-2465
Practice Address - Country:US
Practice Address - Phone:765-286-7000
Practice Address - Fax:765-213-2769
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001667A106H00000X
106H00000X
IN20043496A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist