Provider Demographics
NPI:1508216516
Name:LEE, MARY BRONWYN (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BRONWYN
Last Name:LEE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:M. BRONWYN
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 538622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8622
Mailing Address - Country:US
Mailing Address - Phone:910-742-9243
Mailing Address - Fax:888-746-1787
Practice Address - Street 1:3205 RANDALL PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2564
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:888-746-1787
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2864103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical