Provider Demographics
NPI:1619972767
Name:LEE, FRED THOMAS (PHD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:THOMAS
Last Name:LEE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3194 CORE RD
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-1556
Mailing Address - Country:US
Mailing Address - Phone:304-485-5185
Mailing Address - Fax:304-485-0051
Practice Address - Street 1:3194 CORE RD
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26104-1556
Practice Address - Country:US
Practice Address - Phone:304-485-5185
Practice Address - Fax:304-485-0051
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5576103T00000X
WV179103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1619972767Medicaid
CP14366Medicare ID - Type Unspecified
WV0165206000Medicaid