Provider Demographics
NPI:1710121587
Name:LEE, GLENDA RENEE (COTA)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:RENEE
Last Name:LEE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 REMSEN AVE
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-1819
Mailing Address - Country:US
Mailing Address - Phone:917-476-2907
Mailing Address - Fax:
Practice Address - Street 1:97 REMSEN AVE
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-1819
Practice Address - Country:US
Practice Address - Phone:917-476-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002515-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency