Provider Demographics
NPI:1578983656
Name:JUAREZ, LEE G
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:G
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:S
Other - Last Name:GILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8320 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-6066
Mailing Address - Country:US
Mailing Address - Phone:317-882-5122
Mailing Address - Fax:317-888-8642
Practice Address - Street 1:8320 MADISON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6066
Practice Address - Country:US
Practice Address - Phone:317-882-5122
Practice Address - Fax:317-888-8642
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004869A364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent