Provider Demographics
NPI:1255826129
Name:MICHELSON, LEE ANN (PHD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:MICHELSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:ANN
Other - Last Name:SIMONS MICHELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1 CHARLES ST S UNIT 11C
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5450
Mailing Address - Country:US
Mailing Address - Phone:508-561-6603
Mailing Address - Fax:
Practice Address - Street 1:1 CHARLES ST S
Practice Address - Street 2:UNIT 11C
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116
Practice Address - Country:US
Practice Address - Phone:508-561-6603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-24
Last Update Date:2018-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4096-PY-PR103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical