Provider Demographics
NPI:1619996345
Name:LEE, PAUL KENNETH (ATC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:KENNETH
Last Name:LEE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 LINDEN CIR
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3617
Mailing Address - Country:US
Mailing Address - Phone:662-312-3983
Mailing Address - Fax:
Practice Address - Street 1:400 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2163
Practice Address - Country:US
Practice Address - Phone:662-615-3020
Practice Address - Fax:662-615-3021
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSATO1202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer