Provider Demographics
NPI:1700205580
Name:LEE, LOLETHA
Entity Type:Individual
Prefix:
First Name:LOLETHA
Middle Name:
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 1:765 E HAMILTON AVE
Mailing Address - Street 2:NEW PATHS, INC.
Mailing Address - City:FLIINT
Mailing Address - State:MI
Mailing Address - Zip Code:48505
Mailing Address - Country:US
Mailing Address - Phone:810-233-5340
Mailing Address - Fax:
Practice Address - Street 1:765 E HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48505-4707
Practice Address - Country:US
Practice Address - Phone:810-233-5340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015188103TC1900X
MI6802086823104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No104100000XBehavioral Health & Social Service ProvidersSocial Worker