Provider Demographics
NPI:1437691391
Name:LEE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6432 224TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2318
Mailing Address - Country:US
Mailing Address - Phone:646-670-8155
Mailing Address - Fax:
Practice Address - Street 1:21 GRAND AVE # 1F
Practice Address - Street 2:SUITE 516
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1076
Practice Address - Country:US
Practice Address - Phone:201-313-0313
Practice Address - Fax:201-313-0806
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00080100171100000X
NY004489171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist