Provider Demographics
NPI:1508387119
Name:LEE, KIA (MSW, MBA, LICSW)
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MSW, MBA, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MINNEHAHA AVE E STE 330
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-4437
Mailing Address - Country:US
Mailing Address - Phone:651-717-8011
Mailing Address - Fax:
Practice Address - Street 1:2120 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3378
Practice Address - Country:US
Practice Address - Phone:612-872-2000
Practice Address - Fax:612-871-1375
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235801041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty