Provider Demographics
NPI:1245752088
Name:LEE, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
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 1:3221 35TH ST APT 1N
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-1179
Mailing Address - Country:US
Mailing Address - Phone:646-543-1945
Mailing Address - Fax:
Practice Address - Street 1:38 GRAMERCY PARK N
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7458
Practice Address - Country:US
Practice Address - Phone:646-283-1887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006942101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health