Provider Demographics
NPI:1639639529
Name:LEE, RICKIE L
Entity Type:Individual
Prefix:
First Name:RICKIE
Middle Name:L
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W MONUMENT AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-1274
Mailing Address - Country:US
Mailing Address - Phone:937-461-4300
Mailing Address - Fax:
Practice Address - Street 1:1540 BELVO RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-7807
Practice Address - Country:US
Practice Address - Phone:937-859-4505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician