Provider Demographics
NPI:1548762412
Name:LEE, BRENDA KAY (DT, DE)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:KAY
Last Name:LEE
Suffix:
Gender:F
Credentials:DT, DE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 RAIN HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1878
Mailing Address - Country:US
Mailing Address - Phone:618-604-3287
Mailing Address - Fax:
Practice Address - Street 1:654 RAIN HOLLOW DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1878
Practice Address - Country:US
Practice Address - Phone:618-604-3287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty