Provider Demographics
NPI:1588218762
Name:LEE, ADDISON WYNDHAM (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ADDISON
Middle Name:WYNDHAM
Last Name:LEE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 E BROAD ST APT 3132
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3076
Mailing Address - Country:US
Mailing Address - Phone:704-942-0036
Mailing Address - Fax:
Practice Address - Street 1:117 CHIPWOOD LN
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-1256
Practice Address - Country:US
Practice Address - Phone:503-250-3019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6691235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty