Provider Demographics
NPI:1356636070
Name:LEE, DEREK (PC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26494 LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5484
Mailing Address - Country:US
Mailing Address - Phone:419-874-8798
Mailing Address - Fax:
Practice Address - Street 1:1045 KLOTZ RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-4820
Practice Address - Country:US
Practice Address - Phone:419-352-7588
Practice Address - Fax:419-354-4977
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0900398101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC0900398OtherSTATE OF OHIO COUNSELOR, SOCIAL WORKER, MARRIAGE & FAMILY THERAPIST BOARD