Provider Demographics
NPI:1588675581
Name:LEE, DAVID G (MA, LP, LMFT, LICSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:LEE
Suffix:
Gender:M
Credentials:MA, LP, LMFT, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1852
Mailing Address - Country:US
Mailing Address - Phone:218-525-0280
Mailing Address - Fax:
Practice Address - Street 1:30 10TH ST N
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1634
Practice Address - Country:US
Practice Address - Phone:218-878-2844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 0425103T00000X
MNLICSW 005111041C0700X
MNLMFT 0087106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist