Provider Demographics
NPI:1528541372
Name:LEE, KORI RENEE
Entity Type:Individual
Prefix:
First Name:KORI
Middle Name:RENEE
Last Name:LEE
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 1:9116 LOXFORD ST
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-6413
Mailing Address - Country:US
Mailing Address - Phone:678-416-5594
Mailing Address - Fax:
Practice Address - Street 1:9116 LOXFORD ST
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-6413
Practice Address - Country:US
Practice Address - Phone:678-416-5594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE$$$$$$$$$OtherSOCIAL