Provider Demographics
NPI:1760726640
Name:LEE, ERICA ANN (PSYD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:ANN
Last Name:LEE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 W ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4545
Mailing Address - Country:US
Mailing Address - Phone:410-578-2603
Mailing Address - Fax:410-367-4197
Practice Address - Street 1:1708 W ROGERS AVE
Practice Address - Street 2:DEPARTMENT OF PSYCHOLOGY
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-4545
Practice Address - Country:US
Practice Address - Phone:410-578-2603
Practice Address - Fax:410-367-4197
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05456103TC0700X, 103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD589561800Medicaid