Provider Demographics
NPI:1710318134
Name:LEE, KEVIN (LCSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2790
Mailing Address - Country:US
Mailing Address - Phone:631-264-0058
Mailing Address - Fax:
Practice Address - Street 1:191 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2790
Practice Address - Country:US
Practice Address - Phone:631-264-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090975390200000X
NY0886631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty