Provider Demographics
NPI:1609287028
Name:FANIA LEE PSYD HSPP LLC
Entity Type:Organization
Organization Name:FANIA LEE PSYD HSPP LLC
Other - Org Name:FANIA LEE PSYD HSPP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD HSPP
Authorized Official - Phone:812-455-6597
Mailing Address - Street 1:43 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1317
Mailing Address - Country:US
Mailing Address - Phone:812-455-6597
Mailing Address - Fax:
Practice Address - Street 1:43 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1317
Practice Address - Country:US
Practice Address - Phone:812-455-6597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty