Provider Demographics
NPI:1508434440
Name:LEE, SAMUEL (MS)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3956 BRAVEHEART CIR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7743
Mailing Address - Country:US
Mailing Address - Phone:240-586-9878
Mailing Address - Fax:
Practice Address - Street 1:1003 W 7TH ST STE 403
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-8532
Practice Address - Country:US
Practice Address - Phone:240-586-9878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9754101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health