Provider Demographics
NPI:1225304165
Name:LEE, CLINTON
Entity Type:Individual
Prefix:
First Name:CLINTON
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 1:41-52 63RD STREET
Mailing Address - Street 2:APT. 3A
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41-52 63RD STREET
Practice Address - Street 2:APT. 3A
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377
Practice Address - Country:US
Practice Address - Phone:917-816-6412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033291225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist