Provider Demographics
NPI:1609509595
Name:LEE, KIMICA DEANN
Entity Type:Individual
Prefix:
First Name:KIMICA
Middle Name:DEANN
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25112 THORNRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-9277
Mailing Address - Country:US
Mailing Address - Phone:810-858-5671
Mailing Address - Fax:
Practice Address - Street 1:2425 S LINDEN RD STE D138
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5482
Practice Address - Country:US
Practice Address - Phone:810-230-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022323101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional