Provider Demographics
NPI:1417157371
Name:LEE, BERGEN MATTIE (LMP)
Entity Type:Individual
Prefix:
First Name:BERGEN
Middle Name:MATTIE
Last Name:LEE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 GRANT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-7818
Mailing Address - Country:US
Mailing Address - Phone:509-884-2512
Mailing Address - Fax:509-884-5080
Practice Address - Street 1:667 GRANT RD
Practice Address - Street 2:SUITE 3
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-7818
Practice Address - Country:US
Practice Address - Phone:509-884-2512
Practice Address - Fax:509-884-5080
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024403174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist