Provider Demographics
NPI:1568922490
Name:LEE, RANDALL (LAC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5007
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5007
Mailing Address - Country:US
Mailing Address - Phone:701-852-3628
Mailing Address - Fax:701-852-1190
Practice Address - Street 1:6301 19TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-8899
Practice Address - Country:US
Practice Address - Phone:701-852-3628
Practice Address - Fax:701-852-1190
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1815101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDPENDINGMedicaid