Provider Demographics
NPI:1609195023
Name:LEE, IVY (DC)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DC
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 130403
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-0995
Mailing Address - Country:US
Mailing Address - Phone:917-981-9581
Mailing Address - Fax:212-219-0148
Practice Address - Street 1:191 CANAL ST
Practice Address - Street 2:ROOM 603
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4524
Practice Address - Country:US
Practice Address - Phone:917-981-9581
Practice Address - Fax:212-219-0148
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010745111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor