Provider Demographics
NPI:1508292566
Name:LEE PROENZA, THAIS
Entity Type:Individual
Prefix:
First Name:THAIS
Middle Name:
Last Name:LEE PROENZA
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 1:555 NE 34TH ST APT 1207
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-4016
Mailing Address - Country:US
Mailing Address - Phone:786-970-4749
Mailing Address - Fax:
Practice Address - Street 1:1414 NW 107TH AVE STE 109
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:FL
Practice Address - Zip Code:33172
Practice Address - Country:US
Practice Address - Phone:786-762-2952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCCM100027104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker