Provider Demographics
NPI:1588177117
Name:LEE, BRIAN W
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 UTOPIA PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-4142
Mailing Address - Country:US
Mailing Address - Phone:718-819-6800
Mailing Address - Fax:
Practice Address - Street 1:2333 MORRIS AVE STE B105
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5716
Practice Address - Country:US
Practice Address - Phone:908-686-8764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR008001000225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ46TR008001000OtherLICENSE