Provider Demographics
NPI:1205206133
Name:LEE, KOURTNEY
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 CAMELLIA PL
Mailing Address - Street 2:
Mailing Address - City:GRAMBLING
Mailing Address - State:LA
Mailing Address - Zip Code:71245-2320
Mailing Address - Country:US
Mailing Address - Phone:706-761-5588
Mailing Address - Fax:
Practice Address - Street 1:172 CAMELLIA PL
Practice Address - Street 2:
Practice Address - City:GRAMBLING
Practice Address - State:LA
Practice Address - Zip Code:71245-2320
Practice Address - Country:US
Practice Address - Phone:706-761-5588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health