Provider Demographics
NPI:1386028736
Name:LEE, SONJA WALLACE (MSCJ)
Entity Type:Individual
Prefix:MS
First Name:SONJA
Middle Name:WALLACE
Last Name:LEE
Suffix:
Gender:F
Credentials:MSCJ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-6903
Mailing Address - Country:US
Mailing Address - Phone:901-228-9596
Mailing Address - Fax:
Practice Address - Street 1:901 CHIPPEWA ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-1552
Practice Address - Country:US
Practice Address - Phone:810-232-9950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI38-1359243106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist