Provider Demographics
NPI:1710874359
Name:LEE, SAMANTHA MADISON
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MADISON
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 1:26 BELDEN AVE UNIT 2117
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-3383
Mailing Address - Country:US
Mailing Address - Phone:814-441-3550
Mailing Address - Fax:
Practice Address - Street 1:3180 MAIN ST STE G1
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4237
Practice Address - Country:US
Practice Address - Phone:877-222-0399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-23-69527103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst