Provider Demographics
NPI:1205204484
Name:LEE, SHANNON (MA)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12970 W BLUEMOUND RD.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2531
Mailing Address - Country:US
Mailing Address - Phone:262-780-1020
Mailing Address - Fax:262-780-1022
Practice Address - Street 1:12970 W BLUEMOUND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2607
Practice Address - Country:US
Practice Address - Phone:262-780-1020
Practice Address - Fax:262-780-1022
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor