Provider Demographics
NPI:1437816279
Name:LEE, STEPHANIE (LMT,CMMP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:LMT,CMMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 STILLWOOD FOREST DR SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-5633
Mailing Address - Country:US
Mailing Address - Phone:678-425-7874
Mailing Address - Fax:
Practice Address - Street 1:1725 STILLWOOD FOREST DR SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-5633
Practice Address - Country:US
Practice Address - Phone:678-425-7874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009398225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist