Provider Demographics
NPI:1275752388
Name:LEE, GERALD E (OTR)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:E
Last Name:LEE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 VOGT DR
Mailing Address - Street 2:APT 3
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4973
Mailing Address - Country:US
Mailing Address - Phone:414-234-0003
Mailing Address - Fax:
Practice Address - Street 1:1414 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3018
Practice Address - Country:US
Practice Address - Phone:262-478-0332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3847-026225XH1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHuman Factors
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40885700Medicaid