Provider Demographics
NPI:1619745304
Name:YANDOLI-LEE, THERESA MARIA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIA
Last Name:YANDOLI-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 1:555 OLD PRISON CAMP RD
Mailing Address - Street 2:
Mailing Address - City:POLKTON
Mailing Address - State:NC
Mailing Address - Zip Code:28135-7149
Mailing Address - Country:US
Mailing Address - Phone:704-690-1808
Mailing Address - Fax:
Practice Address - Street 1:5601 EXECUTIVE CENTER DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8863
Practice Address - Country:US
Practice Address - Phone:704-537-1022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19479101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty